LBP in Pregnancy:LBP in Pregnancy:OMT for the MDOMT for the MD

Capt. James J Arnold Capt. James J Arnold D.O.D.O.

Family Physician Family Physician

Andersen AFB, GuamAndersen AFB, Guam

March 15March 15thth 2007 2007

ObjectivesObjectives

Background FactsBackground Facts CaseCase Review the standard approach to LBP in PGReview the standard approach to LBP in PG The Pathology and Physics causing LBP in The Pathology and Physics causing LBP in

PGPG How OMT can helpHow OMT can help Demonstration and teaching of an OMT Demonstration and teaching of an OMT

regiment any doc can useregiment any doc can use

BackgroundBackground

50% of all pregnant women will experience back pain. 50% of all pregnant women will experience back pain. (41% of those woman are experiencing back pain for (41% of those woman are experiencing back pain for the first time)the first time)

More common in women with preexisting back pain, More common in women with preexisting back pain, back pain in a previous pregnancy, advanced maternal back pain in a previous pregnancy, advanced maternal age, and multiparityage, and multiparity

Height, weight, race, fetal weight, and socioeconomic Height, weight, race, fetal weight, and socioeconomic status do not appear to be risk factorsstatus do not appear to be risk factors

Can occur anytime in pregnancy, but obviously much Can occur anytime in pregnancy, but obviously much more prevalent in the second half of pregnancy and more prevalent in the second half of pregnancy and worsens until deliveryworsens until delivery

Pain usually worsens with activity and improves with Pain usually worsens with activity and improves with restrest

80-95% of the time, back pain resolves post-partum80-95% of the time, back pain resolves post-partum

CaseCase

29 yo G1P0 female at 34 weeks gestation 29 yo G1P0 female at 34 weeks gestation with lumbo-sacral pain for 4 weekswith lumbo-sacral pain for 4 weeks

Denies any radicular symptomsDenies any radicular symptoms Pain getting worse with each week of Pain getting worse with each week of

pregnancypregnancy PE shows TTP of paraspinal muscles (L=R) PE shows TTP of paraspinal muscles (L=R)

and pain along the right SI jointand pain along the right SI joint What is you’re A/P?What is you’re A/P?

Standard of CareStandard of Care Lumbago treatment per ACOGLumbago treatment per ACOG

TylenolTylenol Wear low-heel (but not flat shoes) with good arch supportWear low-heel (but not flat shoes) with good arch support Get help when lifting heavy objectsGet help when lifting heavy objects Firm mattress better then softFirm mattress better then soft Good Mechanics: squat down, bend knees and keep back straight Good Mechanics: squat down, bend knees and keep back straight

when liftingwhen lifting Use chairs with good back support, or use small pillowUse chairs with good back support, or use small pillow If having to stand for prolonged periods, take frequent sit breaks 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 with at least one leg propped up on a stool to relieve low back pressurepressure

Sleep on side with pillow between knees or under belly for Sleep on side with pillow between knees or under belly for supportsupport

Heat/Cold TherapyHeat/Cold Therapy Stretches/Exercise/Self-PT – flexion exercises to strengthen Stretches/Exercise/Self-PT – flexion exercises to strengthen

abdomen, extension exercises to strengthen paraspinal musclesabdomen, extension exercises to strengthen paraspinal muscles Other known therapies include support belts, water Other known therapies include support belts, water

therapy, acupuncturetherapy, acupuncture

Standard of CareStandard of Care

Radicular Symptoms/HNPRadicular Symptoms/HNP If pain only, without Neuro deficit, then same as If pain only, without Neuro deficit, then same as

above.above. If significant pain not responding to conservative If significant pain not responding to conservative

therapy, then consider imaging (MRI preferred). therapy, then consider imaging (MRI preferred). Epidural Steroid Injections are acceptable for HNP Epidural Steroid Injections are acceptable for HNP in PGin PG

If progressive neuro-deficits, bladder/bowel If progressive neuro-deficits, bladder/bowel dysfunction then disc surgery can be considered, dysfunction then disc surgery can be considered, but ideally not done until post-partumbut ideally not done until post-partum

C-section only if usual indication (i.e. FTP, Fetal C-section only if usual indication (i.e. FTP, Fetal Distress) exists, but an operative vaginal delivery Distress) exists, but an operative vaginal delivery may be helpful in reducing intrathecal pressuresmay be helpful in reducing intrathecal pressures

Pathology of LBP in Pathology of LBP in PregnancyPregnancy

The enlarged uterus causes a change The enlarged uterus causes a change in weight distributionin weight distribution

With ligamentous attachments to the With ligamentous attachments to the sacrum, the uterus increases sacral sacrum, the uterus increases sacral tilt and subsequently lumbar lordosistilt and subsequently lumbar lordosis

The weakening and separation of the The weakening and separation of the abdominal muscle (diastasis recti) abdominal muscle (diastasis recti) further allow for the above changesfurther allow for the above changes

Obviously this puts an added strain Obviously this puts an added strain on the paraspinal muscle, SI joints, on the paraspinal muscle, SI joints, vertebral facets, and lumbar discsvertebral facets, and lumbar discs

To further complicate To further complicate things….things….

Relaxin does not Relaxin does not discriminatediscriminate Relaxes the ALL and Relaxes the ALL and

PLL of the lumbarsPLL of the lumbars Increase SI mobilityIncrease SI mobility

Relaxin, however, helps Relaxin, however, helps make OMT easy make OMT easy

How OMT can helpHow OMT can help

Use in conjunction with the Use in conjunction with the standard of care!!standard of care!!

What OMT AccomplishesWhat OMT Accomplishes Decrease Lumbar LordosisDecrease Lumbar Lordosis Mobilizes LumbarsMobilizes Lumbars Mobilizes SI jointMobilizes SI joint

Current LiteratureCurrent Literature

Several studies in the OMT literature show a Several studies in the OMT literature show a 50% reduction in symptoms per subjective 50% reduction in symptoms per subjective analysis.analysis. Strong emphasis on treating SI dysfunctionStrong emphasis on treating SI dysfunction Strong support for decreasing lordosisStrong support for decreasing lordosis

Mobilizing lumbars is well supported in the Mobilizing lumbars is well supported in the allopathic literature for regular low back painallopathic literature for regular low back pain

Small study shows significant improvement in Small study shows significant improvement in SI painSI pain

Improvement on MAS, PTD, but no change on Improvement on MAS, PTD, but no change on C-section rate seen on retrospective analysis C-section rate seen on retrospective analysis

Prospective Trial in the worksProspective Trial in the works

OMT for MD’s: OMT for MD’s: Regiment for LBP in Regiment for LBP in

PregnancyPregnancy A regiment that is very similar to the one most DO’s useA regiment that is very similar to the one most DO’s use Can use at every ROB visit where LBP is an issueCan use at every ROB visit where LBP is an issue Very safe and requires no osteopathic diagnosisVery safe and requires no osteopathic diagnosis Addresses the dysfunctions common to all PG pts with LBPAddresses the dysfunctions common to all PG pts with LBP

The Treatment Plan:The Treatment Plan: Stretch the HamstringsStretch the Hamstrings Frog Leg TechniqueFrog Leg Technique SI MobilizationSI Mobilization Chicago RollChicago Roll

Extra StuffExtra Stuff Killer Fingers – for HA’sKiller Fingers – for HA’s Pedal Pumps – for LE edemaPedal Pumps – for LE edema

Stretch the HamstringsStretch the Hamstrings

Hamstrings originate from the pelvic rami and insert Hamstrings originate from the pelvic rami and insert to the posterior femur, so if they are tight lumbar to the posterior femur, so if they are tight lumbar lordosis is further increasedlordosis is further increased

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

Muscle Energy Technique – by stretching the muscle Muscle Energy Technique – by stretching the muscle you inhibit the Golgi-tendon Reflex and as the you inhibit the Golgi-tendon Reflex and as the muscles stretch they will relax and therefore muscles stretch they will relax and therefore lengthen lengthen

Stretch the Stretch the HamstringsHamstrings

The technique (one side at a time):The technique (one side at a time): With pt supine, flex hip to 90 degrees and extend With pt supine, flex hip to 90 degrees and extend

knee until resistance is feltknee until resistance is felt Support the leg by holding the ankle with one hand Support the leg by holding the ankle with one hand

and use the rest of your body as a wall that the pt and use the rest of your body as a wall that the pt will push off ofwill push off of

Have pt attempt to flex knee and bring there leg Have pt attempt to flex knee and bring there leg down pushing against you for 3-5 seconds, then relaxdown pushing against you for 3-5 seconds, then relax

Once relaxed, take the patients leg to the new point Once relaxed, take the patients leg to the new point of resistance and repeat the above 2 more times for of resistance and repeat the above 2 more times for a total of 3 repsa total of 3 reps

At the end of the 3 rep, take the pts leg to new point At the end of the 3 rep, take the pts leg to new point of resistance, then slowly lower leg back down to the of resistance, then slowly lower leg back down to the tabletable

Do the same to the other side!!Do the same to the other side!!

Frog Leg TechniqueFrog Leg Technique

This technique is essentially a muscle energy This technique is essentially a muscle energy technique technique

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

This causes a decrease in lumbar lordosisThis causes a decrease in lumbar lordosis

The Frog Leg Technique:The Frog Leg Technique:

With the pt supine, have the pt With the pt supine, have the pt assume the frog-leg position. assume the frog-leg position. The same exact position you The same exact position you use for a cervical checkuse for a cervical check

Position your hand under the Position your hand under the patient’s pelvis and cup the patient’s pelvis and cup the sacrum so you can pull sacrum so you can pull caudally.caudally.

Have the pt take a deep breath Have the pt take a deep breath in and as they exhale extend in and as they exhale extend their legs straight. You will be their legs straight. You will be able to pull the sacrum able to pull the sacrum caudally during leg extensioncaudally during leg extension

Have the patient bring their Have the patient bring their legs back to the frog leg legs back to the frog leg position, but as they do so position, but as they do so maintain traction preventing maintain traction preventing the sacrum from moving the sacrum from moving cephlad cephlad

Repeat the above 2more times Repeat the above 2more times for a total of 3 repsfor a total of 3 reps

SI MobilizationSI Mobilization By mobilizing the SI joint, you can relieve pain at the jointBy mobilizing the SI joint, you can relieve pain at the joint

In SI dysfunction, the sacrum is seated unevenly in the SI In SI dysfunction, the sacrum is seated unevenly in the SI jointjoint

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

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

I am encouraging the MD’s to treat both sides, so no matter I am encouraging the MD’s to treat both sides, so no matter what the dysfunction, it will likely be treated (treating an what the dysfunction, it will likely be treated (treating an unaffected side will not cause any harm to the patient, if the unaffected side will not cause any harm to the patient, if the technique is done appropriately)technique is done appropriately)

The SI Mobilization Technique:The SI Mobilization Technique:

Place the patient in the lateral Sims Place the patient in the lateral Sims position: pt laying on their side with position: pt laying on their side with their torso turned towards the table their torso turned towards the table (hugging the table); knees slightly (hugging the table); knees slightly flexed. The SI joint you are treating flexed. The SI joint you are treating will be towards the ceilingwill be towards the ceiling

Get behind the pt and take your Get behind the pt and take your cephlad hand and place it on the cephlad hand and place it on the sacrum to stabilize itsacrum to stabilize it

Take your caudal hand and reach Take your caudal hand and reach over and grab the pt’s knee closest over and grab the pt’s knee closest to the ceilingto the ceiling

Have the pt inhale as you bring the Have the pt inhale as you bring the hip into full flexionhip into full flexion

Then have the pt exhale while fully Then have the pt exhale while fully externally rotating the hip and then externally rotating the hip and then extend the legextend the leg

Repeat 3 timesRepeat 3 times You will likely feel an articulation of You will likely feel an articulation of

the SI with your stabilizing hand the SI with your stabilizing hand during the first repduring the first rep

Do the same on the other side!!Do the same on the other side!!

Chicago RollChicago Roll Mobilizing the lumbars relieves pain at the Mobilizing the lumbars relieves pain at the

affected level by allowing the paraspinal affected level by allowing the paraspinal muscles and nerves attached to lay evenly muscles and nerves attached to lay evenly without being stressedwithout being stressed

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

To be performed twice, once from each side of To be performed twice, once from each side of the tablethe table

The Chicago Roll Technique:The Chicago Roll Technique:

With the pt supine, have them With the pt supine, have them interlace their fingers behind interlace their fingers behind their neck with you standing on their neck with you standing on either side of the tableeither side of the table

Hook your cephlad forearm under Hook your cephlad forearm under their arm opposite from you and their arm opposite from you and take your caudad hand and take your caudad hand and stabilize the opposite ASISstabilize the opposite ASIS

With one motion, use your With one motion, use your cephlad arm to lift the pt’s torso cephlad arm to lift the pt’s torso up and over toward your side of up and over toward your side of the table the table

If any lumbars are rotated away If any lumbars are rotated away from you, there will be from you, there will be articulations at that levelarticulations at that level

Repeat above from opposite Repeat above from opposite side!!side!!

CodingCoding For the DO’s (Need to document specific diagnosis and For the DO’s (Need to document specific diagnosis and

level (ie LonL Sacral Torsion, L4 RrSr)level (ie LonL Sacral Torsion, L4 RrSr) 739.3 – Lumbar SD739.3 – Lumbar SD 739.4 – Sacral SD739.4 – Sacral SD 739.5 – Pelvic SD739.5 – Pelvic SD 739.6 – LE SD739.6 – LE SD CPT Codes – 98925 (1-2 body regions), CPT Codes – 98925 (1-2 body regions), 98926(3-4), 98927(5-6), 98928(7-8), 98929(9-10)98926(3-4), 98927(5-6), 98928(7-8), 98929(9-10)

For the MD’sFor the MD’s Lumbago 724.2Lumbago 724.2 SI Pain 739.4SI Pain 739.4 CPT Codes – sorry MD’s, you can’t code for these CPT Codes – sorry MD’s, you can’t code for these

without being a DO. But the satisfaction of making without being a DO. But the satisfaction of making your patient feel better should be rewarding enoughyour patient feel better should be rewarding enough

Take Home PointsTake Home Points

Use OMT in conjunction with standard of Use OMT in conjunction with standard of care (Our friend, Tylenol, behavioral care (Our friend, Tylenol, behavioral modifications, home exercises)modifications, home exercises)

Goals of treatment are to decrease lordosis, Goals of treatment are to decrease lordosis, mobilize the SI’s, and mobilize the lumbarsmobilize the SI’s, and mobilize the lumbars

Stretch Hamstrings, Frog Leg, SI Stretch Hamstrings, Frog Leg, SI mobilization and Chicago Roll at every ROB mobilization and Chicago Roll at every ROB visit with a complaint of LBPvisit with a complaint of LBP

Cure = Delivery (usually)Cure = Delivery (usually) Difficult cases or other concerns, refer to a Difficult cases or other concerns, refer to a

DO colleagueDO colleague

ReferencesReferences My Education from Des Moines University My Education from Des Moines University

Thanks to Dr. David Boesler, DOThanks to Dr. David Boesler, DO.. Bermas, Bonnie; Bermas, Bonnie; Changes to the musculoskeletal system Changes to the musculoskeletal system

during pregnancyduring pregnancy; UpToDate.com, 2006.; UpToDate.com, 2006. Daly JM, Frame PS, Rapoza PA; Daly JM, Frame PS, Rapoza PA; Sacroiliac Subluxation: a Sacroiliac Subluxation: a

common, treatable cause of low-back pain in pregnancycommon, treatable cause of low-back pain in pregnancy; ; Family Practice Research, June 1991.Family Practice Research, June 1991.

Gunnar BJ; Gunnar BJ; A Comparison of Spinal Manipulation with A Comparison of Spinal Manipulation with Standard Care for Patients with Low Back PainStandard Care for Patients with Low Back Pain; New England ; New England Journal of Medicine, November 1999.Journal of Medicine, November 1999.

Issacs, Brandon; Issacs, Brandon; Treatment of Back Pain in Pregnancy: A Treatment of Back Pain in Pregnancy: A Simple Osteopathic ProtocolSimple Osteopathic Protocol; Paper for the Saint Louis ; Paper for the Saint Louis University Dept of Family Medicine, 2000.University Dept of Family Medicine, 2000.

King, Hollis H; King, Hollis H; Osteopathic Treatment in Prenatal Care: A Osteopathic Treatment in Prenatal Care: A Retrospective Case Control Design Study; Retrospective Case Control Design Study; Journal of the Journal of the American Osteopathic Association, December 2003.American Osteopathic Association, December 2003.

Rath, Jean Duffy; Rath, Jean Duffy; Low Back during Pregnancy: Helping Low Back during Pregnancy: Helping Patients take ControlPatients take Control; The Journal of Musculoskeletal ; The Journal of Musculoskeletal Medicine, April 2000.Medicine, April 2000.

Wang SM, Dezinno P; Wang SM, Dezinno P; Low Back Pain during Pregnancy: Low Back Pain during Pregnancy: Prevalence, Risk Factors, and OutcomesPrevalence, Risk Factors, and Outcomes; Green Journal, July ; Green Journal, July 2004.2004.