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 closure. Form closure describes the mechanism where the sacroiliac joint are tightly fit together through the articulating joint surfaces resisting shear forces. Additional compressive force required to maintain stability at the sacroiliac joint is referred to as force closure and includes the action of the muscles and ligaments. (Stuge, Laerum, Kirkesola, & Vollestad, 2004) Decreased stability can result due to laxity of joint capsules and ligaments, decreased muscle strength or decreased co-contraction of stabilizing muscles. This decreased stability can strain the pelvic ligaments producing pain (Pool-Goudzwaard, Vleeming, Stoeckart, Snijders & Mens, 1998).
Although half of
all pregnant women experience some type of back pain during pregnancy there is
limited primary research for clinicians to review. Specifically, there is a
lack of randomized clinical trials evaluating the effectiveness of physical
therapy on treating women with pain experienced during pregnancy. Therefore the level of evidence
in the literature is compromised.
Even many of the secondary articles are low in evidence being mainly
journalistic reviews and portraying more of the author's opinion. Without the correct intervention many
women may develop chronic pain.
This pain can severely limit their daily activities and ability to care
for their children. This review of
the literature was conducted to provide clinicians with information regarding
the effect of physical therapy, including stabilization exercises and patient
education in reducing low back/posterior pelvic pain. The promising results of using a pelvic belt are also
depicted, however additional research is needed since these studies were not
performed on peripartum women. The
information in this review can help clinicians educate patients regarding the
changes that occur during pregnancy and implement an individualized treatment
program that can decrease the chronicity of pain among this population. Throughout this literature review, the
research question investigated was:
Among peripartum women with low back/posterior pelvic pain due to
lumbopelvic instability is rehabilitation consisting of stabilization exercises
and patient education an effective intervention?
Articles for this review were obtained using Ovid with the following databases searched: Medline 1966-present, CINHAL, Cochrane Database of Systematic Reviews, Current Concepts/Clinical Medicine Premedline and Healthstar. The following key words were used in each of the databases as an attempt to uncover as many relevant articles as possible: pelvic pain, low back pain, instability, dysfunction, pregnancy, peripartum, rehabilitation, therapy, exercise, lumbosacral stabilization and pelvic belts. Each of the words was mapped to subject heading to include all possible derivatives of the search words. Low back pain was included as a search word to include all possible articles referring to pregnancy related pain. Boolean OR was used to combine low back pain and pelvic pain, as well as joint instability and dysfunction. When the term peripartum was mapped, it included the term pregnancy; the results from that search was then combined using Boolean AND to the above citings. Lastly, rehabilitation, therapy, exercise, lumbosacral stabilization and pelvic belts were all were searched, with the results combined using Boolean OR. Due to the low number of randomized clinical trials obtained, initially no limits were set in order to acquire all possible articles. However, only articles written in English were gathered for review. References from the articles retrieved were also examined to ensure all relevant articles were obtained. From these references several books were also collected and reviewed for background information. An example of a search history from Medline 1966-present is included in Appendix I. Below is a table summarizing the number of studies screened versus those included in this review.
|
Initial articles retrieved via unfiltered search |
105 |
|
Articles retrieved after filtering for RCTs |
10 |
|
"RCT filtered" articles with true control group |
7 |
|
"RCT filtered" articles with true control group and adequate follow up |
5 |
There is decreased consistency in the literature when defining posterior pelvic pain, with many authors lumping pelvic pain and back pain into one group. Therefore articles discussing back pain were included in this review, if it was clear that the authors were also referring to posterior pelvic pain. Articles discussing solely low back pain were excluded. In order to obtain a high level of evidence for clinical applications, weight was given primarily to the type of study performed. Therefore, the studies obtained were mostly randomized controlled trials and cohort studies, as well as a quasi-experimental trial and cross section analysis. The primary purpose of this review was to examine the effectiveness of physical therapy treating women with low back/posterior pelvic pain as a result of decreased lumbopelvic stability due to the changes that occur during pregnancy.
On a daily basis clinicians treat women who have developed low back/posterior pelvic pain as a result of pregnancy. Little is known however regarding the lumbopelvic instability that may occur or effective treatments to reduce pregnancy-related pain. The following literature review is based on a biomechanical model of lumbopelvic instability as discussed in the introduction section focusing on the impact of physical therapy including stabilization exercises and patient education. Consistent with the biomechanical model, two articles will first be discussed which examine the correlation of sacroiliac joint laxity and pregnancy related pelvic pain. No articles were found that examined the correlation of decreased muscle strength and pregnancy related pelvic pain. Second, the effect of stabilization exercises on low back/posterior pelvic pain will be presented. Lastly, patient education will be examined focusing on the different outcomes between group and individualized education.
Sacroiliac
joint laxity and pregnancy related pelvic pain:
Research is now examining the correlation between the degree of sacroiliac joint laxity and pregnancy related pelvic pain. Damen, et al. (2001), examined the relationship between pregnancy related pain and sacroiliac joint laxity. One hundred sixty three women, at thirty-six weeks of pregnancy were analyzed using a cross-sectional analysis. Sacroiliac joint laxity was measured with Doppler imaging of vibrations. Among these women with asymmetric laxity of the sacroiliac joints, there was a significant correlation between the degree of laxity with pain, level of disability, positive posterior pelvic pain provocation test and active straight leg raise. Therefore, there is a clear relation between the degree of pregnancy-related pelvic pain and asymmetric laxity of the sacroiliac joints (Damen, et al., 2001).
In 2002, Damen, et al., further evaluated the relationship between asymmetric laxity of the sacroiliac joints and the degree of pregnancy-related pelvic pain postpartum. During this study one hundred twenty three women from the above study who were examined at thirty-six weeks' gestation, were also examined at eight weeks' postpartum. The greater difference in asymmetric laxity of the sacroiliac joints was found in the subjects who had the greatest amount of pregnancy-related pelvic pain as well as pain postpartum. These findings also demonstrate that pregnancy related pelvic pain is associated with asymmetric laxity of the sacroiliac joints rather than absolute laxity of the sacroiliac joints (Damen, et al., 2002b). Is it possible then to influence this asymmetric laxity through stabilization exercises?
Effect
of stabilization exercises:
Stability of the sacroiliac joint is enforced by the thoracolumbar fascia and its attachments to lumbar and pelvic muscles ("i.e., the quadratus lumborum, erector spinae, gluteus maximus, gluteus minimus, piriformis, iliacus, latissimus dorsi, as well as transversus abdominis and internal oblique muscles"), which combine with anterior and posterior sacroiliac joint ligaments (Walker, 1992, p. 904). The sacrotuberous ligament further influences stability due to its anatomical attachments with gluteus maximus and piriformis muscles, as well as the thoracolumbar fascia (Pool-Goudzwaard, et al., 1998). Lastly, the shape of the articular surfaces in between the sacroiliac joints also reinforces stability.
Stuge, Laerum, Kirkesola, and Vollestad (2004), examined a physical therapy treatment program evaluating specific stabilizing exercises to decrease posterior pelvic pain after pregnancy and improve functional status and quality of life. Eighty-one women were evaluated using a randomized, single-blinded, clinically controlled study, with a stratified group design based upon location of the patients' pain. The inclusion criteria specified that the pain began during pregnancy or three weeks afterwards. Individualized treatment programs were developed consisting of posture and body mechanic training and specific strengthening of transversus abdominis with coactivation of lumbar multifidus, gluteus maximus, latissimus dorsi, oblique abdominal muscles, erector spinae, quadratus lumborum and hip adductors and abductors. Specifically the patients were taught to isolate the transversus abdominis and then progress to contract the other muscles. The exercises were performed thirty to sixty minutes, three days a week, for eighteen to twenty weeks. This study demonstrated that subjects who performed the stabilization exercises, compared to patients receiving patient education with encouragement to perform ordinary physical activity, had significantly decreased pain (p<0.001), and higher health related quality of life in the areas of physical functioning, physical role and bodily pain. This is one of the few randomized controlled trials performed on this population. A high level of evidence can be obtained from this study do to its randomization, single blinding and excellent follow up.
Two years later Stuge, Veierod, Laerum, and Vollestad (2004) conducted a follow up study on the same eighty-one subjects from the previous study by use of a questionnaire. Seventy-five of the women's responses were analyzed. The above significant differences were maintained two years after delivery. The strength of these results may be attributed to the functional approach used with the specific stabilizing muscles. Using the SF-36, an outcome measurement assessing general health status, the control group continued to demonstrate lower scores of physical health as compared to the intervention group. The control group did show improvement of pain and decreased disability, however the findings were not significant when compared to the treatment group. The authors attributed this finding as a possible result of time and natural healing.
Mens, Snijders, and Stam (2000) found contrasting results to the above study. These authors examined graded exercises of the diagonal trunk muscles, where subjects were able to increase repetitions as tolerated. This was a randomized clinical trial with forty-four women that also examined persistent pelvic pain that began during pregnancy or three weeks afterwards. In contrast to the study performed by Stuge, et al. (2004) these women were instructed in the exercises by videotape. The subjects were randomly assigned to three groups, where one group performed exercises to target diagonal trunk muscles (external and internal obliques, latissimus dorsi, gluteus maximus, and multifidus), the other group strengthened longitudinal trunk muscles (rectus abdominis, erector spinae and quadratus lumborum) and a control group to perform activities of daily living and not exercise. The videotape also included patient education regarding pain, prognosis and therapeutic possibilities, as well as how to use a pelvic belt. The patients were instructed to perform the exercises three days a week, where two series of exercises were performed (isometric and partly nonisometric), with a five-minute rest period in between. Lastly, they were to perform light exercises to improve muscular awareness and recruitment three times a day. After the eight-week intervention, no significant differences were found between the three groups, in pain, fatigue, perceived general health and mobility of the pelvic joints. It is possible that this study did not find similar results to Stuge, et al. (2004) secondary to the decreased intervention period as well as lack of individualized treatment, where patients performed the exercises at home with instructions by videotape and without the supervision of a physical therapist.
Noren, Ostgaard, Nielsen, Ostgaard (1997), analyzed the effect of a differentiated, individualized treatment program on sick leave during pregnancy for women with lumbar back and/or posterior pelvic pain. A total of one hundred thirty five women participated in this prospective, consecutive, controlled cohort study, where the intervention group had fifty-four women and the control group had eighty-one women from another antenatal clinic, where no intervention for pain was provided. In the treatment group, each woman attended five treatments and participated in an individualized treatment program designed for their pain type and intensity. For example, women who had lumbar spine pain performed lumbar spine strengthening exercises, where as women with posterior pelvic pain were instructed to not overload the pelvis and provided with sacroiliac belt. All patients received education regarding anatomy, body posture, vocational ergonomics, pelvic bottom training and relaxation training. Pain intensity in the treatment group significantly decreased (p < 0.05), as well as reduction in sick leave (p < 0.001). The validity of this study however is low secondary to the lack of randomization at one clinic, as well as the lack of similarities between the control and treatment group. An additional weakness of this study was the lack of information regarding the type of strengthening exercise as well as frequency and performance of exercises. Lastly, there was limited amount of treatments, as compared to the above studies.
Effect
of patient education:
Patient education is a vital component of treatment, which empowers patients to control their symptoms throughout their functional activities. This enables patients to alter their posture and body mechanics throughout their day-to-day activities, protecting their lumbar and pelvic regions. The first study published examining the effect of patient education on women with pregnancy related pain was conducted by Mantle, Holmes and Currey in 1981. This was a quasi-experimental trial, which examined the benefits of providing back care advice to women who were in their first sixteen weeks of pregnancy with either pain in the lumbar, sacral or gluteal region. The sample size consisted of ninety-five women. One to six women attended each class consisting of pregnancy related ergonomic education where each individual's occupation was addressed, as well as methods of reducing back pain. The results from this group of women were compared to a control group of fifty-three women who did not receive the above education, and instead were informed of antenatal classes. The similarities of characteristics in the subjects of the control group and treatment group prior to the study, was a strength of this study. Unfortunately, there was very poor follow up, where only forty-six of the ninety-five women attended both classes. The authors describe significant reduction of pain (p <0.01) in the treatment group as compared to the control group, however one must review the results of this study with caution due to the poor follow up and limited outcome measures.
A study with greater validity was a prospective randomized controlled study published by Ostgaard, Zetherstrom Roos-Hansson, and Svanberg in 1994. This study analyzed an education and training program among women with back and posterior pelvic pain during pregnancy. Four hundred and seven women participated in this study, where they were randomly assigned into three groups. One group served as a control while the other two groups received treatment. The treatment consisted of education regarding "anatomy, physiology, postural and body mechanic training, muscle training and relaxation training" (Ostgaard, et al., p. 895) with a written summary provided. Subjects in the first treatment group, B, attended two, forty-five minute classes. The other treatment group, C, received the same education, on an individual basis in five, thirty-minute classes, in four-week intervals throughout their pregnancy. This treatment group also received a training program, of the exercises to be performed on a music cassette with written instructions of the exercises to be performed three days a week. Similar to the above study conducted by Noren, et al., (1997), the specific training exercises were not described. Pain drawings, responses to visual analog scales and sick leave from work were analyzed. Pain was significantly reduced in the treatment groups (p< 0.05), with a significant reduction in sick leave from work in treatment group, C, (p < 0.01). This pain remained reduced in patients from treatment group C; eight weeks post partum (p< 0.05). The validity of this study was strengthened by the large sample size as well as follow up of subjects, however it is challenging to compare the effects of the training program to that of Stuge, et al., (2004) without knowing what muscle groups the exercises targeted.
In 1997, Ostgaard, Zetherstrom, and Roos-Hansson, published a prospective randomized controlled six-year follow up study. This was a follow up study to the above study where at three months; ninety-seven women participated in the study, and eighty-four percent at six years. There was a strong correlation between the control group and in the treatment group B, which received less education, with the frequency of back pain during pregnancy and six years later. It is interesting to note that treatment group, C, with the individualized treatment program and more extensive education did not show that correlation and had decreased pain. The ergonomic education that this group received enabled them to make daily modifications to reduce back and pelvic pain and maintains that reduction six years later (Ostgaard, et al. 1997).
Lastly, the benefits of patient education in physical therapy have also been compared to patients receiving acupuncture. A prospective randomized study conducted by Wedenberg, Moen and Norling in 2000, examined the benefits of patient education with physiotherapy as compared to acupuncture. Sixty pregnant women, with gestational age less than thirty-two weeks, with low back and/or pelvic pain were randomly assigned to receive either acupuncture or physiotherapy. The physiotherapy was conducted in-group sessions where the women received education regarding their condition, ergonomics, correction of faulty posture and home exercise program. The women attended ten treatments, fifty minutes in duration, twice a week. The women in the acupuncture group were given a total of ten treatments, each thirty minutes long. Results analyzed using a two-tailed student's t-test depicted significant decrease (p <0.01) in morning and evening pain in the acupuncture group as compared to the physiotherapy group. There was also a significant decrease in the physiotherapy before-after treatment in evening pain (p <0.01). A weakness of the current study was again a significant drop out rate in the physiotherapy group where eighteen completed the study as compared to the twenty-eight women who completed the acupuncture treatment. In addition, the physiotherapy treatment was given primarily in groups where there was no set protocol and a variety of treatments were provided, where the acupuncture was administered in individual sessions. This could possibly explain the high drop out rate for the physiotherapy group. It is difficult to compare the results of this study to previous studies secondary to the lack of specific information regarding the physiotherapy treatment.
Implications or unresolved questions
This review included studies that displayed the correlation of sacroiliac joint laxity and pregnancy related pelvic pain as well as those that evaluated the effectiveness of stabilization exercises and patient education in physical therapy. Additional research is needed to demonstrate the correlation of lumbopelvic instability and pregnancy related pelvic pain, especially examining the relationship of decreased muscle strength, since the exact etiology is unknown. There is also a need for a true definition of pregnancy related pelvic pain. Throughout the literature there is decreased consistency regarding the defining of pregnancy related pelvic pain, with some articles calling it posterior pelvic pain, while others describe it as low back pain. This further limited the research obtained for this review, because studies focusing on low back pain only were excluded.
It was also difficult to compare studies secondary to differences among subjects, interventions and outcome measures. In regards to stabilization exercises, Stuge et al., (2004) found very favorable results when focusing on an individualized treatment program where patients performed the exercises in physical therapy for eighteen to twenty weeks. The benefits of this approach were maintained two years later. Mens et al., (2000) did not find similar results to this study. In this study women were instructed in the exercises by videotape, which were performed at home, compared to the first study where the subjects performed the exercises under the supervision of a physical therapist. This article did not mention how they measured understanding or compliance with the treatment program. It is also extremely difficult to compare the results of Stuge et al., (2004) to Noren et al., (1997) due to the lack of description of the intervention, as well as decreased intervention period. Clearly, more research is needed in this area with interventions specifically defined.
Within each of the articles discussed, patient education was mentioned throughout the treatments. A couple of the articles presented focused more on the benefits of patient education as compared to stabilization exercises. In 1981, Mantle et al., examined the benefits of patient education on decreasing pregnancy related pain, however had very poor follow up. Ostgaard et al., (1994) also examined patient education with a training program, however were very vague regarding what the training program consisted of. They did portray however that the subjects receiving individualized treatment throughout their pregnancy had more favorable outcomes. In Ostgaard et al., follow up study in 1997, they demonstrated the benefits of the education with an individualized treatment program where subjects continued to have decreased pain. Although favorable results were found it is difficult for clinicians to apply those results to patient care, without knowledge of the specific education given. Wedenberg et al., (2000) also examined the benefits of education provided in physical therapy as compared to the results of acupuncture in decreasing low back and pelvic pain in pregnancy. Decreased pain was observed in both groups, with a greater reduction of pain seen in the acupuncture group. There were however, several limitations of this study, namely the lack of individualized treatment and protocol of physical therapy treatment provided. Therefore, the results of this study have little clinical value.
Lastly, several studies have mentioned the use of a pelvic belt in treating patients with pelvic instability as a result of pregnancy, however no study, to this author's knowledge has been conducted examining the effectiveness of the pelvic belt in decreasing pain among peripartum women. As displayed below, promising results have been obtained by examining the effects of pelvic belts on pelvic stability in both human spine preparations and healthy women. There is however, a strong need for additional research in this area focusing on the benefits of pelvic belts in peripartum women with low back/posterior pelvic pain.
Vleeming, Buyruk, Stoekcart, Karamursel and Snijders (1992), examined the effect of pelvic belts on pelvic stability, by measuring the amount of sagittal rotation in sacroiliac joints. This was measured in six human pelvis-spine preparations, four female and two male. A pelvic belt was positioned above the greater trochanters and bilateral forces were applied to the acetabulums to cause nutation and contranutation of the sacroiliac joints. Measurements were assessed with and without a belt of either 50 N or 100 N tensions. Both the 50 N and 100 N belts caused a significant decrease in rotation of the sacroiliac joints. The difference however, between the two belts was not significant. Interestingly, the belt did not influence four sacroiliac joints, three of which were from the male specimens, and actually increased rotation in one of the male pelvises. It is possible that this difference could be attributed to the anatomic differences of females and males pelvises. The sacroiliac joints in females tend to have smaller and flatter articular surfaces, thus decreased friction. The combination of this and weakening of the pelvic ligaments may cause the instability in the pelvis. The increased friction offered by the pelvic belt can increase the stability of the sacroiliac joints and symphysis (Vleeming, et al., 1992).
In contrast to the above study, Damen, Spoor, Snijders, and Stam (2002), evaluated the influence of a pelvic belt on sacroiliac joint laxity in ten healthy women. Sacroiliac joint laxity was measured using a Doppler imaging scan in five different conditions: without a belt, then with a 50N and 100 N belt at the level of the symphysis and just below the anterior superior iliac spines (Damen, et al., 2002). The tension of the belt did not have a significant effect on the sacroiliac joint laxity (P = 0.39), which is similar to the findings of the above study. However, this study did find a significant effect on the position of the pelvic belt, with application of the belt just inferior to the anterior superior iliac spines (ASIS) producing a significant decrease in sacroiliac joint laxity (P < 0.001). There was also a decrease in sacroiliac laxity with the belt positioned at the level of the symphysis, however it was not significant. These results are similar to Vleeming, et al. (1992), where there was a significant decrease in rotation with the pelvic belt positioned above the greater trochanters. In this current study, they described the position of the belt inferior to the ASIS, which is similar to positioning the belt above the greater trochanters.
Conclusion
The research examined in this review displayed the importance of an individualized treatment program consisting of posture and body mechanic training, as well as specific strengthening of the transversus abdominis with coactivation of multifidus, gluteus maximus, latissimus dorsi, obliques abdominis, erector spinae and quadratus lumborum. It was portrayed that individuals attending a more individualized, supervised treatment with patient education had more favorable outcomes. The research question investigated in this review can not be completely answered due to the lack of consistency among studies in defining pregnancy related pelvic pain, as well as the poor description of interventions. Future research should focus on examining the correlation between lumbopelvic instability and pregnancy-related pain, defining pain specifically by location, and clear descriptions of subjects, interventions and outcomes. The use of a pelvic belt also appears to be promising, however studies examining the effectiveness on peripartum females need to be conducted.
References
Damen, L., Buyruk, H.M., Guler-Uysal, F., Lotgering, F.K., Snijders, C.J., & Stam., H.J.
(2001). Pelvic pain during pregnancy is associated with asymmetric laxity of the
sacroiliac joints. Acta Obstetricia Gynecologica Scandinavica, 80, 1019-1024.
Damen, L., Spoor, C.W., Snijders, C.J., & Stam, H.J. (2002a). Does a pelvic belt
influence sacroiliac joint laxity? Clinical Biomechanics, 17, 495-498
Damen, L., Buyruk, H.M., Guler-Uysal, F., Lotgering, F.K., Snijders, C.J., & Stam, H.J.
(2002b). The prognostic value of asymmetric laxity of the sacroiliac joints in
pregnancy-related pelvic pain. Spine, 27 (24), 2820-2824.
Fast, A., Weiss, L., Ducommun, E., Medina, E., & Butler, J. (1990). Low-back pain in
pregnancy. Abdominal muscles, sit-up performance, and back pain. Spine, 15 (1),
28-30.
Heckman, J.D. & Sassard, R. (1994). Musculoskeletal considerations in pregnancy. The
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LaBan, M.M. & Rapp, N.S. (1996). Low back pain of pregnancy. Etiology, diagnosis,
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227-232.
Mens, J.M.A., Vleeming, A., Stoeckart, R., Stam, H.J., & Snijders, C. J. (1996).
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(11), pp 1363-1370.
Mens, J.M.A., Snijders, C.J., Stam, H.J. (2000). Diagonal trunk muscle exercises in
peripartum pelvic pain: a randomized clinical trial. Physical Therapy, 80, (12),
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Noren, L., Ostgaard, S., Nielsen, T.F., Ostgaard, H.C. (1997). Reduction of sick leave for
lumbar back and posterior pelvic pain in pregnancy. Spine, 22, (18), 2157-2160.
Ostgaard, H.C., Andersson, G. B. J., & Karlsson, K. (1991). Prevalence of back pain in
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Ostgaard, H. C., Zetherstrom, G., Roos-Hansson, E., & Svanberg, B. (1994). Reduction
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Ostgaard, H.C., Zetherstrom, G., & Roos-Hansson, E. (1997). Back pain in relation to
pregnancy: A six-year follow up. Spine, 22, (24), 2945-2950.
Pool-Goudzwaard, A. L., Vleeming, A., Stoeckart, R., Snijders, C. J., & Mens, M.A.
(1998). Insufficient lumbopelvic stability: a clinical, anatomical, and
biomechanical approach to Ôa specific' low back pain. Manual Therapy, 3 (1),
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Stuge, B., Laerum, E., Kirkesola, G., & Vollestad, N. (2004a). The efficacy of a
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Vleeming,
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Appendix I
Example
of Ovid Search of Medline:
Ovid Technologies, Inc. Email Service
------------------------------
Search
for: 18 and 3
Results:
4-15
Database:
Ovid MEDLINE(R) <1966 to November Week 3 2004>
Search
Strategy:
--------------------------------------------------------------------------------
1) pelvic
pain.mp. or Pelvic Pain/ (2731)
2) low
back pain.mp. or Low Back Pain/ (9669)
3) 1
or 2 (12342)
4) instability.mp.
or JOINT INSTABILITY/ (36602)
5) dysfunction.mp.
(112537)
6) 4
or 5 (148085)
7) 3
and 6 (585)
8) peripartum.mp.
or Pregnancy/ (501047)
9) 7
and 8 (27)
10)
rehabilitation.mp. or REHABILITATION/ (53403)
11)
PHYSICAL THERAPY TECHNIQUES/ or therapy.mp. or "PHYSICAL THERAPY
(SPECIALTY)"/
or EXERCISE THERAPY/ (647277)
12)
exercise.mp. or EXERCISE THERAPY/ or EXERCISE/ (114639)
13)
Lumbosacral Region/ or lumbosacral stabilization.mp. (6630)
14)
pelvic belts.mp. or Lumbosacral Region/ (6631)
15) 10
or 11 or 12 or 13 or 14 (788001)
16) 9
and 15 (5)
17) pregnancy.mp.
or PREGNANCY/ (518156)
18) 15
and 17 (20674)
19) 18
and 3 (105)
20) from
19 keep 4-5,17,21,25,32,37,43,52-53,68,73 (12)