Rehabilitation and Regenerative Medicine Treatment and Prevention of Musculoskeletal Pain During...

Rehabilitation and Regenerative Medicine

Treatment and Prevention of Musculoskeletal Pain During Pregnancy

Farah Hameed, MD

Assistant Professor

Director of Women’s Health Rehabilitation

Columbia University Medical Center

Rehab i l i t a t ion and Regenerat ive Med ic ine

Common MSK Conditions in Pregnancy Lumbopelvic pain (low back, SI joint, pubic symphysis)

Lumbar disc herniation

Transient osteoporosis

Carpal tunnel

Rib pain

Hip pain

Foot pain

Heel pain

Pelvic floor dysfunction


Case 1 CC/HPI: 35 year old G2P1 female, 22 weeks pregnant

3-4 weeks of pain located in the left low back, radiating midway down the posterior thigh.

– Tight and pulling

– 3-7/10

– Denies numbness, tingling, weakness, bowel or bladder dysfunction.

– Exacerbating factors include sit to stand, lying down, running.

– Relieving factors include rest.

– She had no pain with her first pregnancy (3 years ago). She was able to run until late in her third trimester with her first pregnancy, but can’t run now

– Prior child delivered vaginally without complication

She is wondering how this will affect the rest of her pregnancy and wants to be able to exercise


Physical Examination Neuro:

– Strength, sensation and reflexes are intact in bilateral lower extremity

– Babinski sign negative

Musculoskeletal:

– Alignment reveals pelvic obliquity.

– Lumbar spine: Tenderness of left SI/long dorsal ligament

– Full Lumbar ROM, decreased in extension due to pain

– Hip: ROM is full. No pain with flexion, adduction , and internal rotation (FADIR) or scour

Special Tests:

Seated slump test and straight leg test are negative

– + low back pain with flexion, abduction , and external rotation (FABER)

– + pain with posterior provocation test (P4)

– Heaviness bilaterally with active straight leg raise, improved with pelvic compression


Epidemiology of Lumbopelvic Pain

During pregnancy

– Prevalence ranges from 4% to 90% across various studies

– SR 28 studies found average prevalence of 45%

Postpartum

– Prevalence ranges from 0.3% to 67%

– SR 18 studies found average prevalence of 25%

Wu, W. H., Meijer, O. G., Uegaki, K., Mens, J. M., van Dieen, J. H., Wuisman, P. I., & Ostgaard, H. C. (2004). Pregnancy-related pelvic girdle pain (PPP), I: Terminology, clinical presentation, and prevalence. Eur Spine J, 13(7), 575-589.

Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine (Phila Pa 1976). 2005;30(8):983-991.


Pathophysiology The underlying mechanism is not been definitively

understood, but may have many factors:

– Biomechanical

– Hormonal

– Inflammatory

– Vascular

– Neural

Joint laxity

Vermani E1, Mittal R, and Weeks A. Pelvic girdle pain and low back pain in pregnancy: a review. (2010) Pain Pract. 10(1), 60-71.

Marnach ML, Ramin KD, Ramsey PS, Song S-W, Stensland JJ, An K-N. Characterization of the relationship between joint laxity and maternal hormones in pregnancy. Obstet Gynecol. 2003;101(2):331-335


Weight gain, 20-40 pounds – (Artal and O'Toole, 2003; Paisley et al, 2003)

Shift in the center of gravity, more upward and forward – (Wang and Apgar, 1998, Ostgaard 1993)

Hyperlordosis and rotation of the pelvis on the femur – (Hartmann and Bung, 1999).

anterior flexion of the cervical spine and adduction of the shoulders

ligamentous laxity – (Hartmann and Bung, 1999; Wang and Apgar, 1998,

Gilleard 1996)


Treatment Initiated Activity modification

Exercise recommendations/alternatives

– ACOG guidelines: Women with uncomplicated pregnancies should be encouraged to engage in 30 minutes or more of moderate intensity exercise on most, if not all, days of the week

Physical therapy with women’s health rehabilitation

Strategies for minimize pain with ADL’s

Sacroiliac belt for standing/walking


Physical Therapy – The Evidence

Exercises can help LBP, not as strong evidence that they can help PGP

Education also plays a role in outcomes

Individualized approach with specific stabilizing exercises more effective – Core strengthening (TA activation) and

force closure (pelvic stabilization)

Exercise is not harmful

van Benten E, Pool J, Mens J, Pool-Goudzwaard A. Recommendations for physical therapists on the treatment of lumbopelvic pain during pregnancy: a systematic review. J Orthop Sports Phys Ther. 2014 Jul;44(7):464-73, A1-15.

http://www.ncbi.nlm.nih.gov/pubmed/24816503




Postural Alignment/Pelvic Tilt Hold your head up straight

Do not tilt the head

Keep your shoulder blades back and your chest upright.

Keep your knees straight, but not locked

Tighten your stomach, pulling your belly button in towards your spine

Point your feet in the same direction, with your weight evenly balanced evenly on both feet


Body Mechanics

Donning/Doffing shoes or boots: Sit in a chair. Cross one leg over and bring your foot onto your thigh. Then place your shoe on your foot and fasten it. When possible, use boots or shoes with zippers or laces to reduce strain removing them.

Lifting: When lifting, always be sure to bend from your knees and hips. Keep item that you are lifting close to your body. Keeping your feet far apart will allow you to get close to the object you are lifting. This will place less strain on your back.

Prolonged standing: Activities that require prolonged standing can cause pain. If you stand for prolonged periods; take breaks, walk around, or sit and rest. You can also place one foot on a low stool (to put the spine into a neutral position).

Sleeping: Sleep on your left side. Use a body pillow to keep your pelvis level. You can also use a pillow in front to hug and use one behind. When turning in bed, keep your knees bent and touching together for added support.

To get into bed, lower yourself onto your side and at the same time bend your knees and pull your legs onto the bed. To get out, place your bottom hand under your shoulder. Slowly raise your body and you lower your legs to the floor.

Getting in/out of a car: First sit on the seat. Sit down first and swing the legs into the vehicle, keeping the knees together

Use a back support at the curve of your back


Prevention

Morkved, Bo 200712 week exercise program

Improved pain compared to controls

Cochrane Review (2015)

– Combined 4 low quality studies (n=1176) found that 8-12 week land based exercise program decreased incidence of LBP, PGP

– 2 studies (n=374) of group exercise/info found no difference in prevention of LBP, PGP


Clinical Course

Started swimming 4x/week

PT/SI belt helped to improve pain

Delivered vaginally without complication

6 week postpartum (PP) – return to run program

3 months PP – back to running 4 miles 3x/wk


Case 2

CC/HPI: 40-year-old G1P0 female with a prior history of a L4-5 microdiscectomy, 20 weeks gestation

6 weeks of left leg weakness, pain, and difficulty climbing stairs.

The pain started bending over in the shower. The patient immediately felt a sharp, stabbing pain in her low back.

The pain now radiates down the left buttock into the posterior calf.

Lying down and bending forward makes the pain worse.

There are no alleviating factors.

The pain is a 9/10 in severity and is associated with tingling and fatigue in the leg.

The patient denies bowel or bladder changes.

Pain worsening despite PT



– Strength, sensation and reflexes are intact in bilateral lower extremity

– Babinski sign negative

Musculoskeletal:

• Alignment reveals mildly flexed forward standing posture abnormality.

– Lumbar spine: No tenderness to palpation over the bilateral greater trochanters, lumbosacral spinous processes or paraspinal muscles.

– Significant pain and limited range of motion with both lumbar flexion and extension. The pain is worse with lumbar flexion.

– Hip: ROM is full. No pain with flexion, adduction , and internal rotation (FADIR) or scour

– Unable to heel walk on the left

Special Tests:

• Positive straight leg raise on the left, negative on the right.

• Positive seated slump test on the left with pain reproduced in the buttock and posterior calf, negative on the right.

– No pain with flexion, abduction , and external rotation (FABER)

– No pain with posterior provocation test (P4)

– No pain/heaviness with active straight leg raise


Lumbar Herniated Disc

Incidence for pregnant women no greater than for general population

Incidence 1:10,000 (LaBan et al)

– Unilateral symptoms 41%, bilateral 21%

Risk higher in older patients

Must differentiate SI joint dysfxn

Dx: MRI lumbar spine


Diagnostic Radiology in Pregnancy

Chen MM, Coakley FV, Kaimal A, Laros RK Jr. Guidelines for computed tomography and magnetic resonance imaging use during pregnancy and lactation. Obstet Gynecol. 2008 Aug;112(2 Pt 1):333-40.



MRI


Treatments

• Women’s health physical therapy (focusing on McKenzie extension-based exercises and pelvic stabilization)

6-day methyl-prednisolone taper (Class C) – no relief

• 2-week prednisone taper - mild relief of symptoms.

• Discussion between the physiatrist, obstetrician, and women’s health physical therapist a birth plan

• Labor modifications and positioning (*C-section?)

• 48 hour treatment of stress steroids post-delivery.


Clinical course

• At 35 weeks, a healthy baby was delivered vaginally via low forceps.

• Post-partum, the pain increased to 10/10 with left ankle weakness

• A L4-5 transforaminal epidural steroid injection was performed.

• The pain improved and then returned - injection was repeated 4 months later.

• She continued physical therapy exercises as well as started acupuncture for 7 months

• She remains pain free today.


Case 3 CC/HPI: 30 yo G1P0 female RN, right hip pain, 25 weeks gestation

Pain is non radiating

Stabbing pain.

Intensity of the pain is 8/10.

Associated symptoms include no numbness, tingling or weakness or bowel/bladder difficulties

Exacerbating factors include bending her hip, standing/walking.

Relieving factors include lying down/sitting.

Onset of the pain was about 3 weeks ago without inciting event. The pain is now causing her to limp. She is walking on her tip toe on the right to avoid the pain.



– Strength,sensation and reflexes intact in bilateral lower extremities

Musculoskeletal:

– Gait reveals antalgia with avoidance of the right

– Lumbar spine: no spinous process, paraspinal tenderness, no SI joint tenderness. Seated slump test and straight leg test is negative. Lumbar facet loading is negative. Full painless lumbar ROM.

– Hip: no lateral or posterior tenderness. No tenderness over the pubic symphysis or pubic tubercle

– She has pain with single leg stance on the right

Special Tests:

– Hip ROM: Decreased on the right due to pain, +++ pain with flexion, adduction , and internal rotation (FADIR), and scour. ++ pain with log roll.

– Mild groin pain with flexion, abduction , and external rotation (FABER), no pain with thigh thrust.

– ++ pain with resisted hip flexion.


Imaging


Transient Osteoporosis of Pregnancy

First described by Curtiss and Kinkaid 1959

3:4,900 pregnancies (Steib-Furno 2007)

Typically final trimester or during lactation

Hip>> knee > ankle, wrist, elbow

MRI imaging of choice

– Can see changes on DEXA, xray, bone scan

Etiology unclear

Exercising pregnant female more likely to have symptoms

Prognosis: good (Phillips 2000)

Possible risk: pathologic fracture


Treatment

Crutches/Walker

Limited weight bearing/modified bed rest

Tylenol recommended for pain at rest

Calcium/Vit D supplementation

Discussion on calcitonin (class C) - deferred

Labor position modification

No physical therapy initiated


Calcium/Vit D Recommendations

Oliveri B1, Parisi MS, Zeni S, Mautalen C. Mineral and Bone Mass Changes During Pregnancy and Lactation. Nutrition 2004. Feb;20(2):235-40.


Complications of TOP

Risk of progression to AVN

Main risk is delivery

Unilateral/bilateral femoral neck fractures have been reported

If symptomatic @ delivery

– Recommendations are C section

Lidder S, Lang KJ, Lee H-J, Masterson S, Kankate RK. Bilateral hip fractures associated with transient osteoporosis of pregnancy. J R Army Med Corps. 2011;157(2):176-178.


Clinical Course/Outcomes

At 38 wks; pain dramatically improved

Delivered vaginally (side lying) without complication at 41 wks

Returned to work & started exercise at 12 wks PP without pain

Remains pain free

Continued Ca/Vit D

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