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LBP in Pregnancy OMT for the MD

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					LBP in Pregnancy:
 OMT for the MD

Capt. James J Arnold D.O.
    Family Physician
  Andersen AFB, Guam
    March 15th 2007
                 Objectives
   Background Facts
   Case
   Review the standard approach to LBP in PG
   The Pathology and Physics causing LBP in PG
   How OMT can help
   Demonstration and teaching of an OMT regiment
    any doc can use
                     Background
   50% of all pregnant women will experience back pain. (41%
    of those woman are experiencing back pain for the first time)
   More common in women with preexisting back pain, back pain
    in a previous pregnancy, advanced maternal age, and
    multiparity
   Height, weight, race, fetal weight, and socioeconomic status
    do not appear to be risk factors
   Can occur anytime in pregnancy, but obviously much more
    prevalent in the second half of pregnancy and worsens until
    delivery
   Pain usually worsens with activity and improves with rest
   80-95% of the time, back pain resolves post-partum
                      Case
   29 yo G1P0 female at 34 weeks gestation with
    lumbo-sacral pain for 4 weeks
   Denies any radicular symptoms
   Pain getting worse with each week of pregnancy
   PE shows TTP of paraspinal muscles (L=R) and
    pain along the right SI joint
   What is you’re A/P?
                  Standard of Care
   Lumbago treatment per ACOG
       Tylenol
       Wear low-heel (but not flat shoes) with good arch support
       Get help when lifting heavy objects
       Firm mattress better then soft
       Good Mechanics: squat down, bend knees and keep back
        straight when lifting
       Use chairs with good back support, or use small pillow
       If having to stand for prolonged periods, take frequent sit
        breaks with at least one leg propped up on a stool to relieve low
        back pressure
       Sleep on side with pillow between knees or under belly for
        support
       Heat/Cold Therapy
       Stretches/Exercise/Self-PT – flexion exercises to strengthen
        abdomen, extension exercises to strengthen paraspinal muscles
   Other known therapies include support belts, water
    therapy, acupuncture
               Standard of Care
   Radicular Symptoms/HNP
       If pain only, without Neuro deficit, then same as above.
       If significant pain not responding to conservative
        therapy, then consider imaging (MRI preferred).
        Epidural Steroid Injections are acceptable for HNP in PG
       If progressive neuro-deficits, bladder/bowel dysfunction
        then disc surgery can be considered, but ideally not done
        until post-partum
       C-section only if usual indication (i.e. FTP, Fetal Distress)
        exists, but an operative vaginal delivery may be helpful
        in reducing intrathecal pressures
         Pathology of LBP in
             Pregnancy
   The enlarged uterus causes a change in
    weight distribution
   With ligamentous attachments to the
    sacrum, the uterus increases sacral tilt
    and subsequently lumbar lordosis
   The weakening and separation of the
    abdominal muscle (diastasis recti)
    further allow for the above changes
   Obviously this puts an added strain on
    the paraspinal muscle, SI joints,
    vertebral facets, and lumbar discs
To further complicate things….

   Relaxin does not
    discriminate
      Relaxes the ALL and PLL
       of the lumbars
      Increase SI mobility

   Relaxin, however, helps
    make OMT easy
           How OMT can help

   Use in conjunction with the
    standard of care!!
   What OMT Accomplishes
       Decrease Lumbar Lordosis
       Mobilizes Lumbars
       Mobilizes SI joint
             Current Literature
   Several studies in the OMT literature show a 50%
    reduction in symptoms per subjective analysis.
       Strong emphasis on treating SI dysfunction
       Strong support for decreasing lordosis
   Mobilizing lumbars is well supported in the
    allopathic literature for regular low back pain
   Small study shows significant improvement in SI
    pain
   Improvement on MAS, PTD, but no change on
    C-section rate seen on retrospective analysis
   Prospective Trial in the works
       OMT for MD’s:
Regiment for LBP in Pregnancy
   A regiment that is very similar to the one most DO’s use
   Can use at every ROB visit where LBP is an issue
   Very safe and requires no osteopathic diagnosis
   Addresses the dysfunctions common to all PG pts with LBP

   The Treatment Plan:
      Stretch the Hamstrings
      Frog Leg Technique
      SI Mobilization
      Chicago Roll


   Extra Stuff
      Killer Fingers – for HA’s
      Pedal Pumps – for LE edema
          Stretch the Hamstrings
   Hamstrings originate from the pelvic rami and insert to the
    posterior femur, so if they are tight lumbar lordosis is
    further increased

   Also, a good hamstring stretch also stretches the
    paraspinal muscles and the quadratus lumborum on the
    side your treating

   Muscle Energy Technique – by stretching the muscle you
    inhibit the Golgi-tendon Reflex and as the muscles stretch
    they will relax and therefore lengthen
       Stretch the
       Hamstrings
   The technique (one side at a time):
      With pt supine, flex hip to 90 degrees and extend knee
       until resistance is felt
      Support the leg by holding the ankle with one hand and use
       the rest of your body as a wall that the pt will push off of
      Have pt attempt to flex knee and bring there leg down
       pushing against you for 3-5 seconds, then relax
      Once relaxed, take the patients leg to the new point of
       resistance and repeat the above 2 more times for a total of
       3 reps
      At the end of the 3 rep, take the pts leg to new point of
       resistance, then slowly lower leg back down to the table
      Do the same to the other side!!
           Frog Leg Technique

   This technique is essentially a muscle energy
    technique

   By pulling caudal traction on the sacrum the
    paraspinal muscle and the ligaments of the lumbo-
    sacral spine get stretched

   This causes a decrease in lumbar lordosis
   The Frog Leg Technique:

       With the pt supine, have the pt
        assume the frog-leg position. The
        same exact position you use for a
        cervical check
       Position your hand under the
        patient’s pelvis and cup the
        sacrum so you can pull caudally.
       Have the pt take a deep breath in
        and as they exhale extend their
        legs straight. You will be able to
        pull the sacrum caudally during leg
        extension
       Have the patient bring their legs
        back to the frog leg position, but
        as they do so maintain traction
        preventing the sacrum from
        moving cephlad
       Repeat the above 2more times for
        a total of 3 reps
                  SI Mobilization
   By mobilizing the SI joint, you can relieve pain at the joint

   In SI dysfunction, the sacrum is seated unevenly in the SI joint

   This is an articulatory technique that takes the SI joint through
    its full range of motion allowing it to reset self evenly back into
    the SI joint

   DO’s are able to make very specific sacrum diagnosis’ allowing
    them to treat only one side (the affected side) and be complete
    in their treatment.

   I am encouraging the MD’s to treat both sides, so no matter
    what the dysfunction, it will likely be treated (treating an
    unaffected side will not cause any harm to the patient, if the
    technique is done appropriately)
   The SI Mobilization Technique:
       Place the patient in the lateral Sims
        position: pt laying on their side with
        their torso turned towards the table
        (hugging the table); knees slightly
        flexed. The SI joint you are treating will
        be towards the ceiling
       Get behind the pt and take your cephlad
        hand and place it on the sacrum to
        stabilize it
       Take your caudal hand and reach over
        and grab the pt’s knee closest to the
        ceiling
       Have the pt inhale as you bring the hip
        into full flexion
       Then have the pt exhale while fully
        externally rotating the hip and then
        extend the leg
       Repeat 3 times
       You will likely feel an articulation of the
        SI with your stabilizing hand during the
        first rep
       Do the same on the other side!!
                  Chicago Roll
   Mobilizing the lumbars relieves pain at the affected
    level by allowing the paraspinal muscles and nerves
    attached to lay evenly without being stressed

   This is an articulatory technique; by taking the
    lumbar through their range of motion the disc spaces
    will gap and lumbars rotated out of place will “pop”
    back into place

   To be performed twice, once from each side of the
    table
   The Chicago Roll Technique:
       With the pt supine, have them
        interlace their fingers behind their
        neck with you standing on either
        side of the table
       Hook your cephlad forearm under
        their arm opposite from you and
        take your caudad hand and
        stabilize the opposite ASIS
       With one motion, use your cephlad
        arm to lift the pt’s torso up and
        over toward your side of the table
       If any lumbars are rotated away
        from you, there will be
        articulations at that level
       Repeat above from opposite side!!
                         Coding
   For the DO’s (Need to document specific diagnosis and level
    (ie LonL Sacral Torsion, L4 RrSr)
      739.3 – Lumbar SD
      739.4 – Sacral SD
      739.5 – Pelvic SD
      739.6 – LE SD
      CPT Codes – 98925 (1-2 body regions),
     98926(3-4), 98927(5-6), 98928(7-8), 98929(9-10)

   For the MD’s
      Lumbago 724.2
      SI Pain 739.4
      CPT Codes – sorry MD’s, you can’t code for these without
       being a DO. But the satisfaction of making your patient
       feel better should be rewarding enough
           Take Home Points
   Use OMT in conjunction with standard of care
    (Our friend, Tylenol, behavioral modifications,
    home exercises)
   Goals of treatment are to decrease lordosis,
    mobilize the SI’s, and mobilize the lumbars
   Stretch Hamstrings, Frog Leg, SI mobilization and
    Chicago Roll at every ROB visit with a complaint
    of LBP
   Cure = Delivery (usually)
   Difficult cases or other concerns, refer to a DO
    colleague
                       References
   My Education from Des Moines University
      Thanks to Dr. David Boesler, DO.
   Bermas, Bonnie; Changes to the musculoskeletal system during
    pregnancy; UpToDate.com, 2006.
   Daly JM, Frame PS, Rapoza PA; Sacroiliac Subluxation: a common,
    treatable cause of low-back pain in pregnancy; Family Practice
    Research, June 1991.
   Gunnar BJ; A Comparison of Spinal Manipulation with Standard
    Care for Patients with Low Back Pain; New England Journal of
    Medicine, November 1999.
   Issacs, Brandon; Treatment of Back Pain in Pregnancy: A Simple
    Osteopathic Protocol; Paper for the Saint Louis University Dept of
    Family Medicine, 2000.
   King, Hollis H; Osteopathic Treatment in Prenatal Care: A
    Retrospective Case Control Design Study; Journal of the American
    Osteopathic Association, December 2003.
   Rath, Jean Duffy; Low Back during Pregnancy: Helping Patients
    take Control; The Journal of Musculoskeletal Medicine, April 2000.
   Wang SM, Dezinno P; Low Back Pain during Pregnancy:
    Prevalence, Risk Factors, and Outcomes; Green Journal, July 2004.

				
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