Interview on Low Back Pain and Pregnancy with Esther Van Benten

Problems in the pelvic region have always had my special attention. To this day, treating people with pain in the pelvic area, gives me so much satisfaction and joy. Not only pregnant women, also people (men and women!) with knee-, shoulder- and hip problems that do not respond to local treatment often recover after treatment of the pelvis and spine. Sometimes, even poorly understood low back and pelvic pain with a psychological origin, abdominal or urinary tract problems, sexual dysfunction and breathing problems can be solved of reduced. I find it challenging to try to use manual therapy, exercise therapy and coaching together. I feel that the pelvis is the basis, the foundation of the human body. I think in this case, multi-disciplinary treatment, to work together with a physician, psychologist or pelvic physiotherapist for example, is one of the nicest things in daily practice.

During my study Orthopedic Manual Therapy, pregnancy was considered a relative contra-indication. Increased joint laxity, relaxine, risks for the unborn child… I have always thought that those arguments were mostly based on fear of doing harm and I never read an article or study that proved that. When I had to choose a subject for my master thesis, I wanted to study whether or not there was evidence for manual therapy in pregnancy-related pelvic pain. I needed evidence to fund my idea that treating pregnant women with pelvic pain would be beneficial and of much importance for this patient category. I did a small descriptive study in my own practice, presented a poster about that and performed a narrative review. I did not find the evidence I was hoping for. Nonetheless, my thesis was well received. My mentor (Dr. J.J.M. Pool) asked me if I would like to publish this review. That’s how I met my co-author (Dr. A. Pool-Goudzwaard) and eventually the other author (Dr. J. Mens) We started working together on my article, and performed the systematic review as it is now. Because there is very little research about manual therapy in pregnancy, we changed the subject to physical therapy, and also included exercise therapy, material support and combination of interventions (mostly education was added). Eventually, our aim was to determine what level of evidence on the treatment of lumbopelvic pain could be reached using methods by the Cochrane Back Review Group. All treatment approaches considered are listed in the policy statement ‘Description of Physical Therapy’ by the WCPT, so it would be of practical value for physical therapists.

Although many differences between measurements and inclusion criteria are present, our review shows that treating a patient with PLBP (pregnancy related low back pain) of PGP (pelvic girdle pain) is better than doing nothing. All included studies on exercise therapy, and most of the studies on interventions combined with patient education, reported a positive effect on pain, disability, and/or sick leave. If you would look at one outcome measure at a time, it could be stated that there is not enough evidence for treating women with PLBP or PGP. In another light, one could say that treating this condition had a positive effect on at least one of the mentioned outcome measures. This nuance is of importance, because it makes the difference between treating the condition or not! And that is a difference with preceding reviews on the topic. Our review gives direction to both clinical practice and scientific research, because exercise therapy and providing information seem promising treatment options.

In the Netherlands, 20% of all pregnant women with lumbopelvic pain seek medical help between week 34 and 40 of pregnancy. (Bastiaenen CH, de Bie RA, Essed GG. Pregnancy-related pelvic girdle pain. Acta Obstetricia et Gynecologica Scandinavica2007;86(4):416-22 )

I see at least one pregnant woman a day in our practice. I guess women think that physical therapy is a good option for their complaints, because pain occurs in movement and daily activities. At least in the Netherlands, physical therapists are known for their ability to help in that case. Moreover, some of them are sent by their obstetrician. I think that is a very positive development.

1. To understand the relationship between their activities, rest and physical capacity

2. To maintain, and if necessary improve, stability, strength and mobility of their spine and pelvis. (But actually of their whole body)

3. To take care of the pelvic floor and breathing

4. Joint dysfunctions can be treated with manual therapy

(What I think, as you asked, is a combination of my clinical experience and the main findings of our review)

Strictly, I can not answer this question, because I do not have evidence to underline my answer. But I think that any treatment that is omitting to look at the patient as a whole (physical factors, emotional factors, occupation, other children etc.) is a waste of effort. It is very important to establish on what factor you can resolve. For some women, exercise focusing on strength and stability will be helpful, to others, relaxation, belly breathing and providing information does the trick. That is in line with our review, combining modalities seems promising, as well as patient education.

I think that the Active Straight Leg Raise test tells the therapist a lot about the stability and compensation of dysfunctional movement. I it is very important to me to carefully look at the way a women moves in various situations typically for her.

Moreover, specific examination of the joints of the lower back and SI-joints, position of the sacrum and hips often yield many treatment indications.

Albert et al. proposed a test protocol for classification of pregnenacy-related pelvic pain, an interesting article with tests I use every day:

Albert H, Godkesen M, Westergaard J. Evaluation of clinical tests used in classification procedures in pregnancy-related pelvic joint pain. Eur Spine J 2000;9:161-166

Quite a lot has been written about this. Our review did not specify exercises. It is a very interesting topic though. Important to remember is the risk of a diastasis of the m. rectus abdominis. It is normal that the linea alba weakens during pregnancy, as a result of more laxity of the tissue and the uterus getting bigger and heavier. Normally, both sides of the rectus abdominis grow together again after the baby is born. If not, a gap is palpable around the belly button, mostly above it, but sometimes under it as well.

Very tight and strong abdominal muscles are a risk factor for this, but weak ones are as well!

During pregnancy, women should train their abdominals in functional movement, and not isolated. Bridging, performing squats and lunges are examples of functional movements, crunches are isolated. It is very important that women learn to implement basic principles like breathing out when performing strength, tighten the pelvic floor together with deep abdominal and back muscles. A physical therapist is of great importance in this case.

This review was my first publication, and I hope more will follow. Right now, together with Dr. Pool-Goudzwaard, I am designing a fundamental study, investigating the (changed?) activity of the pelvic floor in women with pelvic girdle pain by TMS (Transcranial Magnetic Stimulation) I am also planning to design an RCT on the effect of a specified training program for pregnant women with PGP.