Thesis

When trying to decide on a thesis topic I asked the advice of Dr. Raza Awan who put forth postpartum women with lower back pain as an underserved population. When performing my literature review it was difficult to separate out low back pain and posterior pelvic girdle pain (sacroiliac joint pain related to pregnancy and postpartum) in the literature. Two European multidisciplinary guidelines were tantamount to providing definitions and distinguishing the difference between chronic low back pain and posterior pelvic girdle pain in studies going forward:

2006 European Guidelines for Chronic Low Back Pain

• Chronic Non-specific LBP

• Pain for 12 weeks or more

• Localized below costal margins, above inferior gluteal folds with or without referred leg pain

2008 European Guidelines for Posterior Pelvic Girdle Pain

• Pain between posterior iliac crest and gluteal fold particularly in the region of the sacroiliac joint

• Risk factors identified as osteoarthritis, trauma or pregnancy

These European Guidelines identified treatment options for pregnancy and postpartum low back pain as:

• Manual therapy

• Specific Stabilization Exercise (SSE)

• Acupuncture

• Pain medication

• Stability belt

The following is an abridged version of my thesis with a focus on results of statistical significance that may be of interest to the reader. It is in point form for the ease of the reader not used to reading research studies.

The Effects of Global Osteopathic Treatment on Postpartum Low Back Pain:

As Measured Using the Short Form McGill Pain Questionnaire 2 with Visual Analogue Scale and MyotonPRO Myometer - A Pilot Study

Annalene (Riki) Richter

Thesis Advisor: Katharine Liberatore

CMCC Ethics Review Board

HYPOTHESES

Global osteopathic treatment will decrease postpartum low back pain, as measured using the Short Form McGill Pain Questionnaire 2 (p ≤.05) compared to a control group watching videos on postpartum health and back care and a control group performing specific stabilization exercise.

Global osteopathic treatment will decrease postpartum low back pain, as measured using the MyotonPRO Myometer (p ≤.05) compared to a control group watching videos on postpartum health and back care and the control group performing specific stabilization exercise.

Global osteopathic treatment will decrease postpartum low back pain and increase quality of life as measured using the Visual Analogue Scale (p ≤.05) compared to a control group watching videos on postpartum health and back care and the control group performing specific stabilization exercise.

PURPOSE

• Test the efficacy of Global Osteopathic Treatment on Postpartum Low Back Pain

• Test the relationship between pain and viscoelastic tissue parameters tested

OUTCOME MEASURES

• Short Form McGill Pain Questionnaire 2

• Visual Analogue Scale

• MyotonPRO Myometer

Short Form McGill Pain Questionnaire 2

• 22 descriptors for total score of 220

• Assesses both neuropathic and non-neuropathic pain

• Present pain intensity is based on a 0-10 scale

• Excellent reliability and validity especially if filled out in clinic (0.95)

Visual Analogue Scale

• Included to catch any treatment outliers

• Questions on pain, overall mood, overall health and continence

• Subject placed mark on line

• Reliability is excellent (0.97) with pain (Price 1982, Bijur 2001)

MyotonPro Myometer

• Self - calibrating measurement tool used in this study

• Measures viscoelastic quality of tissue

• Class 1 Medical Diagnostic Device

• Reliability .95-.99 intra-rater within session (Bailey 2013, Mullix 2013)

  Measures viscoelastic properties of skeletal muscle:

  • Tone - state of resting tension / muscle’s resistance to passive stretch

  • Elasticity - muscle’s ability to recover shape after deformation

  • Stiffness of tissue - ability to resist force that modifies its shape

RESEARCH METHODOLOGY

Target Population

• Female

• Under the age of forty

• 3 months to 3 years postpartum

• Experiencing low back pain

Inclusion Criteria

• Natural vaginal birth(s)

• Onset of low back pain with pregnancy or after delivery that had been present for six weeks or more

• 3 months to 3 years postpartum

• Ability to speak and read English

• Cleared by physician to exercise

• Positive P4 Test or Positive ASLR Test

• Signed informed consent

Active Straight Leg Raise Test (ASLR)

• Measures ability to transfer load from legs to trunk via SIJ to lumbar spine

• Ipsilateral innominate should posteriorly rotate (anteriorly rotates with + test)

• Ipsilateral IO and EO and contralateral hip extensors required to counteract force placed on innominate by ipsilateral hip flexors

• Insufficiency in TA and IO results in pelvic rotation on a transverse plane

• Altered respiration or breath holding, increased IAP associated with + test)

• Grade 0=Not at all difficult (- Test Result)

• 1 minimally difficult to 5=unable to do (+ Test Result)

Posterior Pelvic Pain Provocation Test (P4)

Measures whether MSK and ligamentous systems have been consistently overloaded resulting in decreased force closure at the SIJ

Specific to the SIJ (whereas as the ASLR will include the SIJ)

Manual pressure along long axis of femur results in posterior pelvic pain

(+ Test Result)

Exclusion Criteria

• Previous spinal surgery or being a present candidate for spinal surgery

• Low back pain caused by spondylolysis, spondylolisthesis, rheumatoid arthritis, osteoarthritis, osteoporosis, spinal stenosis, ankylosing spondylitis, diagnosed disc herniation, infection or fracture

• Presently taking prescription pain medication

• Presently receiving osteopathy, physiotherapy, chiropractic or other forms of manual therapy treatment

• Presently involved in a specific stabilization exercise class

• Caesarean section

• Over the age of 40

• Currently pregnant

Dependent Variables

• Short Form McGill Pain Questionnaire 2 Score

• Visual Analog Scale Score

• MyotonPRO Myometer Score

• Length of treatment

Independent Variables

• Osteopathic treatment

• Specific stabilization exercise

• Home exercise routine

Procedure

First Appointment 1 1/2 hour:

• Informed Consent

• Short Form McGill Pain Questionnaire 2 with Visual Analogue Scale

• P4 and ASLR Tests

• MyotonPRO Myometer

• Measurements taken at midpoints of

• Gluteus medius: Superior iliac crest and apex of greater trochanter)

• Erector spinae: L3 transverse process and spinous process

The study design followed a quasi-experimental parallel three group design. Female subjects were randomly assigned to either one of two control groups or an experimental group. A power analysis determined that a sample size of 15 subjects per group (n=45) was needed to have statistical significance in all measurement outcomes. This pilot study had 23 subjects and was made into a pilot study.

Control group A consisted of eight subjects that participated in a single session postpartum health and back care information seminar. Control group B consisted of five subjects that participated in a six week specific stabilization exercise (SSE) program. SSE is designed to improve the motor performance of both local and global lumbar stabilization musculature that participates in spinal movement (Haladay, D. E.; Miller, S. J.; Challis, J.; Denegar, C. R. 2013).

The experimental group C consisted of ten subjects that received six weekly global osteopathic treatments. A pre-test, mid-test and post-test assessment were conducted using the SF-MPQ-2 with VAS and the MyotonPRO Myometer. A three month followup SF-MPQ-2 with VAS up was administered on control group B and experimental group C.

Control Group A: DVD Group

1 appointment

Included to create a baseline measurement. Watched a DVD “Postpartum Health for Moms: An Instructional and Exercise Class for Restoring the Core” by Diane Lee

Control Group B: Specific Stabilization Exercise Group

6 x 1 hour weekly specific stabilization exercise class

Exercises targeted:

• Transversus abdominus and multifidus: in various positions, in isolation, in co-contraction and with limb loading

• Pelvic floor musculature (focus on anterior portion)

• Hip extensors / gluteals in bridging progressing to transverse plane movement

• Functional sit to stand

• Posterior portion of the diaphragm

• Small component of stretching hamstrings /strengthening back extensors, oblique sling

• Evidence-based protocols

Experimental Group C: Osteopathic Treatment Group

6 x 1 hour weekly global osteopathic treatments

• Treats barriers to health particular to patient

• Simultaneously treats across different systems and their inter-relationships to attain homeostasis

• Profound effect on health of patient

Measurement Outcome Timeline