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The Relationship between Exercise and Back Pain During Pregnancy

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									The Relationship between
 Exercise and Back Pain
   During Pregnancy
  Jennifer Y. McElroy, D.O.
     Sheila Dugan, M.D.
                Objective
 Investigate  self-reported back pain
  and patterns of physical activity in
  the first and second trimester of
  pregnancy to evaluate the
  relationship between exercise and
  back pain during pregnancy
 Demonstrate the applicability of
  published pain scale models to the
  pregnant population
            Background
 Studies have shown 50-90% of
  pregnant women experience back
  pain during pregnancy
 Back pain cited as the most frequent
  reason for missed work days in
  pregnant population
 Proposed etiologies range from
  biomechanical strain to altered
  hormonal influences
            Background
 ACOG   recommends 30 minutes of
  moderate exercise on most days of
  the week for pregnant patients
 Benefits of exercise during
  pregnancy include fetal and maternal
  benefits (decreased GDM, labor,
  general discomforts)
             Hypothesis
 An  exercise program during
  pregnancy may prevent or minimize
  the intensity of low back pain during
  pregnancy
 Little research has been published to
  support or debase this hypothesis
     Materials and Methods
 Power  analysis performed: 66
  patients needed
 Women’s Health Care Resident Clinic
  population enrolled
 Patients consented and enrolled
  through the months of November
  2005 to April 2006.
      Materials and Methods
 Inclusion  criteria: 18-34 years of
  age, singleton gestation, and the
  ability to read and write English
 Exclusion criteria
 45 women enrolled, 10 excluded
  based on criteria
 Socioeconomic information, presence
  and severity of back pain and
  patterns of activity were evaluated
Trimester distribution of study participants




  Trimester          Number of patients
  First trimester           18
  Second trimester          17
  Respective Focus of each Pain Questionnaire


Pain Questionnaire          Focus

McGill Pain Questionnaire   Pain Description

Oswestry Questionnaire      Perceived Functional Status

Numeric Rating Scale        Pain Intensity

Physical Activity Index     Physical Activity Level

Physical Discomforts of     Physical Discomforts
Pregnancy
                   Results
   Data collected from 35 women
    – Black 77.1%
    – Hispanic 17.7%
    – White 5.7%
 Four (11.4%) participants reported a
  history of back pain prior to the current
  gestation
 Three participants (8.6%) reported back
  pain during the current gestation
    Demographics and Reported Back Pain


                                              Back Pain
            Enrolled       Back Pain prior       this
            Population     to pregnancy       pregnancy
Black       77.1% (n=27)   7.4% (n=2)        3.7% (n=1)
Hispanic    17.7% (n=6)    0.0 % (n=0)       16% (n=1)
White       5.7% (n=2)     100% (n=2)        50% (n=1)
Married     40% (n=14)     14.2% (n=2)       7.1% (n=1)
Single      60% (n=21)     9.5% (n=2)        9.5% (n=2)
All                        11.4% (n=4)       8.6% (n=3)
Enrollees
               Results
 Higher than expected activity level in
  the enrolled population
 Eighty percent of those enrolled
  reported walking at least twice a
  week (4.7x a week average)
 Seventy-three percent of the study
  population reported that they
  engaged in regular strenuous activity
Reported incidence of Walking and Strenuous Exercise




                   Walking as          Strenuous
                   Exercise            Exercise

 Black             77.7% (n=21)        66.6% (n=18)
 Hispanic          83.3% (n=5)         100% (n=6)
 White             100% (n=2)          100% (n=2)
 Married           85.7% (n=12)        78.5% (n=11)
 Single            76.2% (n=16)        71.43% (n=15)
 All enrollees     80.0% (n=28)        73.5% (n=25)
             Discussion
 Our  hypothesis was that an exercise
  program may prevent or minimize
  the intensity of back pain during
  pregnancy
 Collected data reveal a higher than
  expected level of physical activity in
  this study population, and
  coincidentally, a lower than expected
  incidence of back pain
             Discussion
 Pre-pregnancy   levels of activity did
  not predict levels of activity during
  pregnancy
 The low frequency of reported back
  pain precluded meaningful statistical
  analysis and identification of risk
  factors
            Discussion
 Given the low reported incidence of
 back pain in this active population it
 appears that a more active lifestyle
 may be protective against some of
 the discomforts experienced by
 pregnant patients.
     Areas for Further Study
 Evaluation of risk factors that may
  predispose pregnant women to back
  pain with respect to physical activity
 Pregnancy conditioning regimens and
  outcomes with respect to back pain
                              Exclusion Criteria
                                                                           Selected obstetric complications which present prior
   Exclusion Criteria                                                      to 34 weeks:
                                                                             –    Polyhydraminios
   Age <18 or >34                                                           –    Oligohydramnios
   Multiple gestation                                                       –    Pre-eclampsia
   Unable to read/write English                                             –    Congenital viral disease
                                                                             –    Maternal surgical conditions
   History of back surgery                                                  –    Suspected fetal abnormality
   Considered to have high-risk pregnancy by                                –    Isoimmunization with antibody titers greater than 1:8
    health care provider. Examples include:                                  –    Antiphospholipid syndrome
                                                                             –    DES exposure
   History of one or more of the following:                                 –    IDDM Class A2 and B
     –   Prior neonatal death\
     –   Two or more previous preterm deliveries <34 weeks                 Selected chronic medical conditions with a known
     –   A single preterm delivery <30 weeks                                increase in perinatal morality:
     –   Birth of a neonate with serious complications resulting in a        –    Cardiovascular disease with functional impairment
         handicapping condition                                              –    Respiratory failure requiring mechanical ventilation
     –   Recurrent spontaneous abortion or fetal demise                      –    Acute coagulopathy
     –   Family history of genetic disease
                                                                             –    Intractable seizures
   Incompetent cervix                                                       –    Coma
   Active chronic medical problems including:                               –    Sepsis
     –   Cardiovascular disease                                              –    Solid organ transplant
     –   Autoimmune disease                                                  –    Active immune disease requiring corticosteroids
     –   Reactive airway disease requiring treatment with                         therapy
         corticosteroids                                                     –    Instable reactive airway disease
     –   Seizure disorder                                                    –    Renal disease requiring dialysis or a serum creatinine
     –   Hypertension controlled on a single medication                           >1/5mg%
     –   Controlled hyperthyroidism on replacement therapy                   –    Active hyperthyroidism
     –   Idiopathic thrombocytopenia purpura
                                                                             –    Severe hemoglobinopathy
     –   Thromboembolic disease
     –   Malignant disease                                                 Selected obstetric complications which present prior
     –   Renal disease with functional impairment                           to 32 weeks
     –   HIV                                                                 –    Preterm labor
                                                                             –    PROM
                                                                             –    Severe pre-eclampsia
                                                                             –    Isoimmunization with need for intrauterine
                                                                                  transfusion
                                     References
1.    Fast, A., Shapiro, D., Ducommun, E.J., Friedmann, L.W., Bouklas, T., & Floman, Y. (1987). Low-back pain in
      pregnancy. Spine, 12, 368-371.
2.    2 Noren, L., Ostgaard, S., Johansson, G., & Ostgaard, H.C. (2002). Lumbar back and posterior pelvic pain during
      pregnancy: a 3-year follow-up. European Spine Journal, 11, 267-271.
3.    3 Ostgaard, H.C. & Andersson, G.B. (1991). Previous back pain and risk of developing back pain in a future
      pregnancy. Spine, 16, 432-436.
4.    4 Kristiansson, P., Svardsudd, K., & von Schoultz, B. (1996). Bak pain during pregnancy: a prospective study.
      Spine, 21, 702-709.
5.    5 ACOG Committee Obstetric Practice (2002). ACOG Committee Opinion. (Rep. No. 267)
6.     6 Clapp, J.F., III, Kim, H., Burciu, B., & Lopez, B. (2000). Beginning regular exercise in early pregnancy: effect on
      fetoplacental growth. American Journal of Obstetrics and Gynecology., 183, 1484-1488.
7.    Clapp, J. F., III, Kim, H., Burciu, B., Schmidt, S., Petry, K., & Lopez, B. (2002). Continuing regular exercise during
      pregnancy: effects of exercise volume on fetoplacental growth. American Journal of Obstetrics and
      Gynecology186,142-147.
8.    Clapp, J. F., III & Little, K.D. 91995). Effect of recreational exercise on pregnancy weight gain and subcutaneous
      fat deposition. Medicine & Science in Sports & Exercise., 27, 170-177.
9.    Dye, T.D., Knox, K.L., Artal, R., Aubry, R.H., & Wojtowyz, M.A. (1997). Physical activity, obesity, and diabetes in
      pregnancy. American Journal of Epidemiology, 146, 961-965.
10.   Clapp, J.F., III (1990). The course of labor after endurance exercise during pregnancy. American Journal of
      Obstetrics and Gynecology., 163, t-805.
11.   Horns, P.N., Ratcliffe, L.P., Leggett, J.C. & Swanson, M.S. (1996). Pregnancy outcomes among active and
      sedentary primiparous women. JOGNN- Journal of Obstetric, Gynecologic, & Neonatal Nursing., 25, 49-54.
12.   Peterson, A. M., et al. (2005). Exercise in pregnancy. Medicine & Science in Sports & Exercise, 37, 1748-53.

								
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