ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research
1061
SEPTEMBER 2012
VOL 4, NO 5
BIOMECHANICAL CHANGES IN THE LOWER BACK DURING THE
THIRD TRIMESTER OF PREGNANCY DR.MARIA AHMAD
1,DR.MUHAMMAD SALMAN BASHIR
2.DR.SYED IMTIAZ
HUSSAIN SHAH3,DR IMRAN GHAFOOR
4.
SCHOOL OF ALLIED HEALTH SCIENCES CHILDREN HOSPITAL LAHORE,RIPHAH INTERNATIONAL UNIVERSITY
LAHORE,RIPHAH INTERNATIONAL UNIVERSITY LAHORE,KING EDWARD MEDICAL UNIVERSITY LAHORE.
ABSTRACT
Pregnancy is a period of various physiological and ph ysical adaptations. During
this process a lot of biomechanical changes are confronted by the female body.
These biomechanical changes, although temporary, lead to debilitating back pain
especially in the lumbar area. They may include sway back posture, leg length
discrepancy, hormonal changes, stretched and weakened muscles and
compression of sciatic nerve. Objective: This study is aimed at determining the
biomechanical changes in the lower back of pregnant females which is their
cause of discomfort .Method: This observational study included 50 females in
their third trimester of pregnancy that completed a questionnaire regarding their
low back pain and i ts potentially influencing factors. The data was collected
from patients coming to the gynecology departm ent of Fatima Memorial
Hospital, Lahore. Results: Showed that out of 50 patients, leg length
discrepancy occurs in 24%, lumbar curve exaggeration in 58%, muscle girth
difference in 20%, and radiating sciatic like pain in 50% of pregnant females.
Previous history of back pain is also an evident factor in predisposition of low
back pain in pregnancy. Conclusion: Hence it is concluded that lower back pain
is common in pregnant women especially in their third trimester. Females with a
history of back pain are more likely to develop discomfort during pregnancy.
The timing of symptom onset in mid to late pregnancy may suggest that
biomechanical factors particularly postural imbalances play a larger role than
hormonal influences.
Keywords: BIOMECHANICAL CHANGES ; LOWER BACK ; THIRD
TRIMESTER OF PREGNANCY
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research
1062
SEPTEMBER 2012
VOL 4, NO 5
INTRODUCTION:
During pregnancy, women gain 25 to 35 pounds, on average, and undergo
multiple hormonal changes and biomechanical alterations which impact the
musculoskeletal system, result ing in back pain. Exagge rated lordosis of the
lower back causes the weight of the growing baby to be carried by the pubic
bones at the front of the pelvis and by the abdominal muscles exerting more
pressure on the pelvic floor muscles and the pelvic ligaments. A significant
increase in the anterior tilt of the pelvis occurs and stance is widened to
maintain trunk movement.
Hormonal fluctuations are bound to cause some discomfort and as
pregnancy progresses, the concentration of relaxin hormone rises causing laxity
of the joints and ligaments so as to accommodate the growing uterus and provide
enough room for the baby to be delivered. Joint laxity in the longitudinal
ligaments of the lumbar spine creates more instabili ty and can predispose to
muscle strain. Relaxin also causes th e abdominal muscles to expand sideways
leading to diastasis recti. Multiple births and repeated pregnancies aggravate the
condition.
Sacro Il iac joint dysfunction may also be caused by hormonal changes.
There is widening and increased mobility of the sa croiliac joints and pubic
symphysis in preparation for the fetus ' passage through the birth canal causing
altered joint mechanics and pain. Some pregnant women may experience
sciatica, a sharp pain down the back of the thigh that is caused by one of the
nerves of the thigh being squashed as it travels down the leg. Sciatica and
pregnancy go together for many women simply because the additional stress of
carrying the baby is what pushes the body beyond its ability to adapt. Those
underlying disc injuries are exacerbated by the weight and posture of pregnancy,
resulting in sciatic nerve disturbance and sciatica pain, either in the back, the
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research
1063
SEPTEMBER 2012
VOL 4, NO 5
buttocks or the legs . In susceptible women, pregnancy may be a factor for the
development of degenerative spondylolisthes is.
METHODOLOGY:
Study design:
Observational study.
Sample design:
Convenience method.
Settings:
The study will be conducted at the Department of Gynaecology, Lahore General
Hospital and the Department of Gynaecology, Fatima Memorial Hospital, Lahore .
Duration of study:
3 months after the approval of synopsis.
Study group:
Pregnant women in their 3rd
t rimester.
Sample size:
This was a time based study of 3 months. 50 patients were included in that period
of t ime.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research
1064
SEPTEMBER 2012
VOL 4, NO 5
Sampling Technique:
Convenient and Purposive Non Random Sampling technique w as used.
Sample selection criteria:
Inclusion criteria:
1. Prima gravida
2. Pregnancy in its 3rd
t rimester
3. Patients up to 35 years of age
Exclusion criteria :
1. C-section
2. Gestational diabetes
3. Patients undergoing pre eclempsia
4. Multiple pregnancy
Methodology:
The assessment is done according to the postural -structural-biomechanical
model (PSB):
Static postural examination:
The shape of the back is observed, whether there are anyincreases in spinal
curves such as scoliosis, kyphosis or lordosis.
Pelvic angleis measured in the coronal plane, pelvic nutation and
counternutation angles, the relative position of the sacrum to the ilia and leg
length differences.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research
1065
SEPTEMBER 2012
VOL 4, NO 5
Dynamic assessment:
It is done in standing in which the spine is examined in all plane of motion.
Regional and segmental movement losses and stiffness is observed and often
used to determine the severity of the spinal condition and is also used to explain
the cause of the condition.
Palpatory examination:
It is performed during standing or lying on the treatment table. Information is
gathered about abnormal t issue textures, unusual muscle stiffness or abnormal
relationships between body masses, muscle bulks or position of vertebral
landmark
Data Collection Tools/Instruments
Structure questioner guide was used to collect data. From these questionnaire
data was collected about patients, gender, age and medical history of disease
STATISTICAL ANALYSIS:
Using SPSS v.17 the data was managed and anal yzed. The continuous variables
were expressed as mean ±S.D. whereas categorical variables were expressed in
the form of frequency table and percentages. Appropriate graphs are used to
display the data.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1066
AUGUST 2012
VOL 4, NO 4
RESULTS: This observational study was based on 3 m onths’ time period and 50
patients were studied. A Performa was used for each patient, which was filled
out based on history and examination. All of the patients were pregnant females under the age of 35,
primagravidas and in their third trimesters as cons idered in the inclusion
cri teria. Their body has undergone numerous changes to accommodate the
growing baby inside. 44% of these women were 40 -45 kg before getting
pregnant. 54% of them were 50 -55 kg and only 2% were 60-65kg. During their
third trimester the weight of 44% women has increased to 60 -65 kg whereas 64%
of them were in the range of 70-75kg.
This increase in weight was confronted by the body by adaptation of some
biomechanical changes which helped them in carrying the increasing load of the
baby.
When asked, al l of them responded with the same answer of debilitating
back pain and spinal stiffness. Out of 50 patients 31 had the history of previous
back pain.
On examination of leg length 24% of the pregnant women presented with
leg length discrepancy which in other words is shortening of one leg causing
postural and gait deformities. 20% of the pregnant women showed girth
difference in arm, thigh and leg muscles.
56% of them had positive radiating, sciatic -like pain in their back and
legs. Out of these 22% women had pain radiating up to knee, 24% had pain up to
foot and 4% had pain radiating in both legs.
On postural examination, 58% of them showed exaggerated lumbar curve
which was caused by stretched abdominal muscles and weakened spin al muscles.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1067
AUGUST 2012
VOL 4, NO 4
DISCUSSION:
The purpose of my study was to determine the biomechanical changes
occurring in the lower back during the third trimester of pregnancy. These
changes although help females to carry their growing fetus, they have an
extremely painful and discomforting effect and lead to functional disability in
women at this period of time.
The factors responsible for back pain are postural changes that are leg
length discrepancy, girth difference in the muscles of arms, thighs and legs,
lumbar curve exaggeration and radiating pain in the lower limbs caused by
compression of sciatic nerve.
This study proves that the most influencing features among these are the
previous history of back pain. The second most promising biomechanical change
is the compression of sciatic nerve leading to radiating pain followed by leg
length discrepancy and girth differences.
These changes and the weakening and stretching of spinal muscles form a
vicious circle and continue to debil itate the body image of pregnant fem ale and
cause severe low back pain.
Many similar studies have been carried out with respect to this problem. I
suggest that research should be done and implemented in fields of pregnancy
counseling and training of postural awareness and control with the he lp of
proprioceptive and therapeutic techniques so as to strengthen the pregnant body
image and avoid weakening of related musculature.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1068
AUGUST 2012
VOL 4, NO 4
CONCLUSIONS:
Lower back pain is common in pregnant women especially in their third trimester. Females with a history of back pain are more likely to develop discomfort during
pregnancy.
The timing of symptom onset in mid to late pregnancy may suggest that
biomechanical factors particularly postural imbalances play a larger role than
hormonal influences.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1069
AUGUST 2012
VOL 4, NO 4
REFERENCES:
Bastiaenen, C.H.G., Hendriks, E.J .M., Pool -Goudzwaard, A.L., Bernards,
N.T.M., Grupping-Morel, R.A. de Bie., and KNGF -richtl i jn, (2009)
Zwangerschapsgerelateerde bekkenpijn, Nederlands Tijdschrif t voor
Fysiotherapie,Jaargang 119 · 1 ; (D)
Bullock, JE., Jull , GA., and Bullock, MI. (1987) The Relationship of Low Back
Pain to Postural Changes During Pregnancy. The Australian Journal of
Physiotherapy . 33(1):10-17.
Endresen, EH. (1995) Pelvic pain and low back pain in pregnant women – an
epidemiological study. Scan J Rheumatol . ; 24 : 135–41.
Eyal, Lederman. (2010) CPDO Ltd. 15 Harberton Road, London N19 3JS, UK.
CPDO Online Journal , March, p1-14. www.cpdo.net
Fast, A. , et al (1987) . Low-back pain in pregnancy . Spine ;12 :368–71.
Franklin, ME. and Conner-Kerr, TJ., (1998) Orthop Sports Phys
Ther.;28(3):133-8.
Gilleard, W., Crosbie, J . , and Smith, R.(2002) Effect of pregnancy on trunk
range of motion when sit t ing and standing . Acta Obstet Gynecol Scand ; 81 :1011
Ireland, ML. and Ott , SM. Kentucky Sports Medicine , Lexington 40517, USA.
Jensen, R.K., Doucet, S., and T. Treit (1995) Centre for research in human
development and school of human movement .
Jenny, E. ( 2009)
Karzel, RP., and Freedman, MJ. (1991) Orthopedic injuries in pregnancy. In:
Exercise in Pregnancy, 2nd ed, Artal , R, Wiswell , RA, Drinkwater, BL (Eds),
Lippincott , Will iams and Wilkins, Balt imore.
Kausar S., Tajammul, A., Sheikh, S., Iqbal, S., and Anwar, S., (2007)
Mantle, MJ., Greenwood, RM., and Currey, HL.(1977) Backache in pregnancy.
Rheumatol Rehabil . ; 16 :95-101.
Majchrzycki M, Mrozikiewicz PM, Kocur P, Bartkowiak-Wieczorek J ,
Hoffmann M, Stryła W , Seremak-Mrozikiewicz A, Grześkowiak E Katedra i
Klinika Rehabili tacji Uniwersytetu Medycznego w Poznaniu.
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1070
AUGUST 2012
VOL 4, NO 4
Pennick, V. and Young, G.(2008) Interventions for preventing and treating
pelvic and back pain in pregnancy.
Russell , R., and Reynolds, F. (1997) Back pain, pregnancy, and childbirth.
British medical journal ; 1059-1064.
Sanderson, PL. , and Fraser, RD (1996) The influence of pregnancy on the
development of degenerative spondylolisthesis. J Bone Joint Surg Br ; 78 :951–4
Saraste, H: (1986) Spondylolysis and pregnancy: A risk analysis . Acta Obstet
Gynecol Scand ;65 :727–9
Stone, C. (2007) Visceral and Obstetric Osteopathy. Philadelphia: Churchil l
Livingstone, Elsevier, . Ch 10.
Svensson, HO., Andersson, GB., Hagstad, A., and Jansson, PO. (1990) The
relationship of low-back pain to pregnancy and gynecologic factors. Spine ;
15 :371–5.
Wang, et al (2004) Obstetr ics & Gynecology: - Volume 104 - Issue 1 - pp 65-70
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1071
AUGUST 2012
VOL 4, NO 4
PERFORMA FOR DATA COLLECTION
Study serial no. Date of assessment:
Name of patient: Age:
Address: Contact no.
Socioeconomic status: Upper Middle Lower
Age at marriage:
Parity status: Primagravida Multigravida
Any previous history of back pain: Yes No
Trimester of pregnancy: 1st 2
nd 3
rd
Weight before pregnancy: 40-45kg 50-55kg 60-65kg
Weight during pregnancy: 50-55kg 60-65kg 70-75kg
Complain of spinal stiffness: Yes No
Leg length discrepancy: Yes No
Length: Right Left
Girth measurement: Right Left
Arm:
Thigh:
Leg:
Observation of lumbar curve: Normal Exaggerated
Radiating pain: Yes No
Please specify if yes:
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1072
AUGUST 2012
VOL 4, NO 4
TABLES:
Weight before and during pregnancy:
History of back pain:
FEATURES
RANGE
FREQUENCY
PERCENTAGE
WEIGHT BEFORE
PREGNANCY
40-45kg
50-55kg
60-65kg
22
27
1
44%
54%
2%
WEIGHT DURING
PREGNANCY
50-55kg
60-65kg
70-75kg
0
18
32
0%
36%
64%
FACTOR FREQUENCY PERCENTAGE
HISTORY OF BACK
PAIN
YES
NO
31
19
62%
38%
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1073
AUGUST 2012
VOL 4, NO 4
Percentage of normal and exaggerated lumbar curve:
Percentages of biomechanical changes responsible for back pain in pregnancy.
Percentage of radiating pain and its distribution.
LUMBAR CURVE VALUE FREQUENCY
NORMAL 21 42%
EXAGGERATED 29 58%
FACTORS CAUSING
BACK PAIN
VALUES
PERCENTAGE
LEG LENGTH
DISCRIPANCY
12
24%
GIRTH DIFFERENCE
10
20%
RADIATING PAIN
28
56%
RADIATING PAIN
FREQUENCY
PERCENTAGE
NO PAIN
25
50%
PAIN UP TO KNEE
11
22%
PAIN UP TO FOOT
12
24%
PAIN IN BOTH LEGS
2
4%
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1074
AUGUST 2012
VOL 4, NO 4
Frequency of biomechanical changes in pregnancy.
Normal and exaggerated lumbar curve:
ijcrb.webs.com
INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS
COPY RIGHT © 2012 Institute of Interdisciplinary Business Research 1075
AUGUST 2012
VOL 4, NO 4