Case ReportChiropractic Management of Pregnancy-Related Lumbopelvic Pain: A Case Study
Introduction
There are discrepancies to defining lumbopelvic pain in the pregnant population.1, 2 Current terminology, pain topography, functional disabilities, and positive correlation of clinical testing have demarcated the classification of pregnancy-related lumbopelvic pain (PR LPP) into subgroups: pregnancy-related low back pain (PR LBP) and pregnancy-related pelvic girdle pain (PR PGP).2, 3, 4
Careful observation of the clinical features of PR LPP can help distinguish the seriousness of the potential symptoms and prognosis. Pain has shown to influence pregnant women’s daily lives and the challenges they encounter concerning their physical, psychological, occupational, and social function.1, 2, 3, 4, 5, 6, 7, 8 Defining PR LPP is imperative for the early diagnosis and effective management of PR LPP to improve quality of life.5 A recent prospective cross-sectional descriptive study9 by midwives demonstrated that the majority of pregnant women agreed that “LPP was expected because of the pregnancy.” Only 25% recounted receiving any form of back treatment. In early pregnancy, women classified with combined low back pain and pelvic girdle pain exhibit the highest risk for persistent pain postpartum, functional disability, and recurrence of PR LPP in subsequent pregnancies.5, 6, 10
There is no “gold standard” for diagnosing PR LPP,4, 10 and this diagnosis is dependent on assessing clinical features, including etiology and risk factors, symptoms and pain topography, functional disabilities, and positive results to provocation tests.
Etiology continues to be considered as unknown,6 but some reported that trigger factors include hormones,11 biomechanics, trauma, metabolic factors, inadequate motor control, and stress of the ligament structures.2, 12, 13 Symptoms of PR LPP can begin as early as the first trimester or at any stage during the pregnancy. Risk factors for developing PR LPP are strongly related to a history of previous low back pain, previous trauma to the pelvis, multiparity, and a high work load.5 Pregnancy- related low back pain has been defined2 as pain between the 12th rib and the gluteal fold throughout the course of the pregnancy. Pregnancy-related back pain shares clinical symptoms to nonpregnancy nonspecific low back pain,2, 3, 4 including dull pain exacerbated by forward flexion, associated erector spinae pain upon palpation, and associated restriction in lower spinal movement.
Pregnancy-related pelvic girdle pain is defined as pain located from the level of the posterior iliac crest, the gluteal fold, and over the anterior and posterior elements of the pelvis during the course of the pregnancy. Pregnancy-related pelvic girdle pain also includes symphysis pubis pain syndrome and leg disturbances. The pain may radiate across the hip joint and femur,7 lacking a typical nerve root distribution.4 In PR PGP, functional abilities are compromised including endurance capacity for standing, walking, and sitting.
Pain provocation and palpation tests increase the sensitivity and specificity to the diagnosis of PR LBP and PGP if 3 or more give a positive test response.2 These tests include posterior thigh test, Patrick’s FABER, Gaenslen’s test, modified Trendelenburg, distraction of the sacroiliac joint, active straight leg raise, responses to pain palpation of the dorsal longitudinal sacroiliac ligament, and palpation of the symphysis.
Although complementary and alternative medicine (CAM) has gained popularity among pregnant women, efficacy studies are still in the “infancy” days.14, 15, 16 Studies suggest that spinal manipulation therapy (SMT) may be an effective and safe intervention in PR LPP.17, 18, 19
A recent randomized chiropractic clinical trial18 reported on the combination of multimodal and obstetric management in PR LPP. Obstetric care included usual prenatal consultation. Multimodal care involved chiropractors providing manual therapy, stabilization exercises, and patient education. The combination of management shows a greater improvement in pain and physical function as compared with just usual obstetric care.
In an observational prospective cohort study of 115 patients,20 most pregnant patients undergoing chiropractic treatment reported clinically relevant improvement at every interval of time analyzed.
Evidence-based research in chiropractic care and SMT16, 17, 18, 19 is beginning to provide alternative back pain management in PR LPP. The purpose of this case study is to describe the chiropractic care of a patient diagnosed with the combination of PR LBP and PR PGP which was managed concurrently with usual medical obstetric care.
Section snippets
Case Report
A healthy 35-year-old female gravida 4 at 32 weeks’ gestation presented for chiropractic care with moderate to severe PR LPP and leg pain. Pain was located bilaterally at the posterior iliac crest, the gluteal fold over the anterior and posterior elements of the bony pelvis, and into the left posterior thigh and calf muscle. The patient also reported constant “uncomfortable” tension in neck and shoulders. The value given to a 0-10 numeric pain rating scale of her back and leg was rated at 7.
Discussion
The efficacy of chiropractic care urgently requires further validation because of its growing popularity in pregnant women who seek alternative pain relief. In this case study of PR LPP, the patient also presented with a clinical history of infertility and of miscarriages due to fetal abnormalities, and this pregnancy was the result of successful in vitro fertilization intervention. Chiropractic management and monitoring of the patient with usual obstetric care resulted in an improvement in
Conclusion
The purpose of this case was to describe chiropractic management of a patient with PR LPP. Successful results were recorded using patient-reported outcomes to monitor changes. This patient reported improvement of pain and functional movement during a combination of chiropractic musculoskeletal management along with usual obstetric care.
Funding Sources and Conflicts of Interest
No funding sources or conflicts of interest were reported for this study.
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