|Year : 2021 | Volume
| Issue : 2 | Page : 63-69
Multidisciplinary management of musculoskeletal pain during pregnancy: A review of literature
Valeska Beatrice Ferreira1, Leandro Ryuchi Iuamoto2, Wu Tu Hsing2
1 Clinical Research Center, Institute of Physical Medicine and Rehabilitation, Clinics Hospital, University of São Paulo Medical School (HCFMUSP), São Paulo, SP, Brazil
2 Center of Acupuncture, Institute of Orthopedics and Traumatology, Clinics Hospital, University of São Paulo Medical School (HCFMUSP), São Paulo, SP, Brazil
|Date of Submission||15-Jul-2020|
|Date of Decision||01-Mar-2021|
|Date of Acceptance||02-Mar-2021|
|Date of Web Publication||01-Jun-2021|
Dr. Leandro Ryuchi Iuamoto
Rua Dr. Ovídio Pires de Campos, 333-Cerqueira César, São Paulo, SP 05403-010
Source of Support: None, Conflict of Interest: None
Introduction: Women may have higher prevalence of musculoskeletal chronic pain than men. Some studies suggest that biomechanical changes during pregnancy are related to elevated chronic pain prevalence. Objectives: The objective of this study is to conduct a review of studies involving strategies in multidisciplinary rehabilitation for musculoskeletal pain management during the pregnancy and the postpartum period. Methodology: The elaboration of the scientific question considered pregnant patients (population), rehabilitation with multidisciplinary team (intervention), without any comparatives, and pain management in any region of the body (outcome). The research was conducted in the databases: Medline (via PubMed) - www.pubmed.com and EMBASE - www.embase.com. Results: A total of 972 articles were found. Only two articles were related to rehabilitation with a multidisciplinary team for the management of pain in pregnant women. These articles were selected based on their relevance and data update. Conclusion: Although the literature has well established the cost-effectiveness of using multidisciplinary strategies for chronic pain control and intervention in its factors, there are no well-defined protocols for the application of these strategies in pregnant women, as shown by the scarcity of studies found on the subject in the bibliographic survey to perform this review. This reinforces the need for further studies with objective assessment parameters that analyze the effectiveness of multidisciplinary approach to musculoskeletal pain control and prevention of chronicity in pregnant women.
Keywords: Chronic pain, exercise, pregnancy, pregnancy outcome, rehabilitation
|How to cite this article:|
Ferreira VB, Iuamoto LR, Hsing WT. Multidisciplinary management of musculoskeletal pain during pregnancy: A review of literature. J Int Soc Phys Rehabil Med 2021;4:63-9
|How to cite this URL:|
Ferreira VB, Iuamoto LR, Hsing WT. Multidisciplinary management of musculoskeletal pain during pregnancy: A review of literature. J Int Soc Phys Rehabil Med [serial online] 2021 [cited 2021 Jun 13];4:63-9. Available from: https://www.jisprm.org/text.asp?2021/4/2/63/317385
| Introduction|| |
Women are more affected by musculoskeletal chronic pain than men, and this difference is probably associated with the biomechanical changes that occur during pregnancy., It is estimated that about 25% of pregnant women experience some temporary disability during pregnancy. Among the most common musculoskeletal disorders during gestation, we can mention low back pain (50%–75%), pelvic girdle pain (20%),, and cramps (75%). At this time in a woman's life, there is also a higher risk of peripheral neuropathies' development such as carpal tunnel syndrome, with a prevalence of 11%–63% according to the trimester of pregnancy,,, in addition to De Quervain's tenosynovitis, meralgia paresthetica, and lumbosacral neuropathies.,, Such comorbidities lead to pain, impaired quality of life,, and higher rates of absenteeism in this population.,,
Among the factors that alter joint overload in pregnancy, we can mention the action of relaxin, which increases ligamentous laxity, predicted biomechanical changes throughout the gestation, and weight gain, which varies according to the woman's previous BMI,,, because it is estimated that every 20% of extra weight increases the joint overload by about 100%.
Women's biomechanics are strategically altered during pregnancy to reduce energy spending associated with gait and to maximize motor safety to perform tasks daily. Changes in gait include changes in stride size, which allows the broadening of the support base; increased ground contact time during the gait cycle; pelvic anteriorization; and lumbar lordosis alteration of kinematics and kinetics of the lower limb moments. Besides, as pregnancy progresses, abdominal muscle distension, strength reduction, and contraction of the pelvic and lumbar muscles can occur.
Some studies suggest that some of these changes are perpetuated after delivery, generating impact on postpartum functionality,,, and may lead to disabling pain in the postpartum. However, there are still few studies evaluating this correlation during and after gestation.
Pain management in pregnant women includes pharmacological and nonpharmacological strategies. During pregnancy, codeine and acetaminophen can be used; during postpartum period, nonsteroidal anti-inflammatory drugs. Lidocaine and dexamethasone can also be used for carpal tunnel syndrome. Other medications for pain management were considered as Category B by the Food and Drugs Administration (FDA): prednisone, cyclobenzaprine, and oxycodone.
Some studies suggest as nonpharmacological management: osteopathy techniques, physical therapy,,, acupuncture,,, Yoga, resistance exercise, pelvic strengthening exercises, transcutaneous nerve stimulation, and relaxation.
A recent review published in 2015 in Cochrane showed that the strategies such as isolated therapies for rehabilitation for low back pain and pelvic pain in pregnancy present low/moderate level of evidence and noticed the need for further studies evaluating the benefit of multidisciplinary intervention strategies. The present study aims to study the multidisciplinary therapeutic strategies for the management of musculoskeletal disorders during the pregnancy and the postpartum period.
The objective of the study is to conduct a review of studies involving strategies in multidisciplinary rehabilitation for musculoskeletal pain management during the pregnancy and the postpartum period.
| Methodology|| |
The elaboration of the scientific question was based on the PICO strategy, considering pregnant women and postpartum period women (population), rehabilitation with multidisciplinary team (intervention), without comparatives, and pain management/relief in any region of the body outcome.
The studies included in the analysis involved literature reviews, clinical trials, and randomized and nonrandomized cohort studies. The studies were included according to their relevance and data update.
Studies were excluded if: (1) were performed on animals, (2) assessed pain during pregnancy or postpartum period, (3) patients had pain of gynecological origin, (4) postoperative pain cesarean section, (5) patients with surgical proposal, (6) osteomuscular comorbidities asymptomatic, and (7) nonmusculoskeletal pain. Case reports, case series, letters to the editor, incomplete articles, study protocols, and unpublished studies were not considered in this review because of the low level of evidence and reliability.
The research was concluded in 1 month (from May to June 2019) without restriction of language or date of publication. The search was performed on Medline (via PubMed) –www.pubmed.com and EMBASE – www.embase.com databases. Using PubMed's search tool, we selected MeSH terms from publications more relevant to perform a new search to get more articles that could be included in this review.
Questions were answered by consulting experts in the field or by contacting directly with the authors of the articles.
The keywords used were the same in all databases, respecting their heterogeneities (e.g., MeSH terms have been translated into Emtree terms). The keywords used were “;Pregnancy,” “Postpartum Period,” “Rehabilitation,” “Physical and Rehabilitation Medicine,” “Pain Management,” and “Pain.”
The search strategy was ((Pregnancy) OR (Postpartum Period)) AND ((Rehabilitation) OR (Physical and Rehabilitation Medicine)) AND ((Pain Management) OR (Pain)).
Data from each of the studies were extracted independently by two authors. Relevant data about strategies involving rehabilitation with multidisciplinary team in pregnant women and postpartum period women were extracted. All disagreements were resolved by consensus. If no consensus was reached, a third author would be consulted. All studies were analyzed according to their titles and abstracts following the inclusion and exclusion criteria. If the eligibility criteria were reached, the entire text would be extracted. All included whole texts have been described in session results. Doubtful or missing data were collected through direct contact with the authors of their articles.
All parameters about the demographic characteristics of the studied population were analyzed, such as age (years), weight (kg), height (m), body mass index (BMI), marital status, and gestational age at the beginning of the intervention. Social parameters such as employment situation, pain localization, and pain risk factors were analyzed: sleep quality (period in hours) and week work load (hours).
| Results|| |
A total of 972 articles were found. Only two articles were considered related rehabilitation with a multidisciplinary team for pain management in pregnant women. Those articles were selected based on their relevance and updated data.
The demographic characteristics of studies are presented in [Table 1], and the pain risk factors in the population analyzed are summarized in [Table 2].
The study conducted in 2011 by George et al. evaluated the results of a model of multidisciplinary intervention associated with chiropractic care for pregnant women with pain lumbar and pelvic. In this study, a total of 169 women aged 15-45 years and gestational age 24-28 weeks passed in consultation with the obstetrician and were evaluated for the presence of low back pain, pelvic pain, or both pains. They passed in consultation with the obstetrician and were evaluated for the presence of low back pain, pelvic pain, or both pains. Pregnant women were excluded if they have presented acute inflammatory disease, chronic low back pain (>8 months), mental illness, peripheral vascular disease, use of substances, and litigation. Pregnant women with radiculopathies or neurological symptoms in the lower limbs were not excluded.
A chiropractor conducted randomization among the volunteers and the randomization was performed. Three subjective questionnaires (numeric pain scale, personal pain history [PPH], and Quebec task force disability questionnaire [QDQ]) and four tests (extended leg dorsal ligament elongation) were used to quantify pain at 24 and 28 weeks of gestational age.
In the control group, the obstetrician provided at least one of pain therapies: local heat, rest, aerobic exercise, and use of acetaminophen for mild pain or narcotics for refractory pain the other measures. For the intervention group, the interventions included pain education program (based on the biopsychosocial model), and manual therapy stabilization and conducted by a chiropractor and with weekly meetings [Table 3].
The pregnant women were reevaluated at the 33rd week of pregnancy, and the results presented in [Table 1] and [Table 2] show that there was no significant difference between the groups in weight, height, age, gestational age at the start of treatment, hours of sleep before pregnancy, and hours of sleep after pregnancy. In the subjective questionnaires, there was an improvement of pain in the intervention group (with a statistically significant difference from the control group) in seven of the physical tests, compared with pain improvement in only one of the physical tests in the control group [Table 3]. Women in the control group noted increased levels of pain in relation to the initial consultation in five of the tests. There was no statistically significant difference between groups regarding medication prescription, sleep problems, and absenteeism at work [Table 3].
Beyaz et al. introduced the concept of rehabilitation in pregnancy and proposed an aerobic exercise program for pregnant women along with stretching, strengthening, relaxation, and breathing exercises, with the objective of evaluating how this program impacted lower back pain, cramps, and outcomes at birth. The study included 36 pregnant women aged 18–35 years in the second trimester of pregnancy without contraindications for physical activity. The exercise program started to pregnant women in the second trimester of pregnancy (30–33 weeks) and the intervention group consisted of pregnant women who could perform the exercise program 3× a week until the 37th gestation week [Table 3]. The exercise plan included aerobic, relaxation, by Kegel, as well as an educational program with counseling on change physiological disorders in pregnancy, musculoskeletal disorders' ergonomic counseling, mechanical body, and dietary guidelines. The exercise sessions were supervised by a physiatrist, and there is no detail of the physical examination tests used to assess low back pain and cramps. Impact of rehabilitation on obstetric outcome was also evaluated, with information about birth, weight gain during pregnancy, complications at birth, need for episiotomy, neonatal complications, APGAR, birth weight, and head circumference. The study showed that the patients who underwent the rehabilitation program had better results. However, compared to the control, there was no significant difference in pain complaint of cramps. In addition, weight gain during pregnancy was lower in the intervention group. There was no significant difference in the parameters: birth weight, prematurity, duration of labor, and complications during delivery between the groups.
| Discussion|| |
Pharmacological control of pain during pregnancy should be done with caution because of the risk of fetal complications, such as malformations, low birth weight, and neonatal bleeding.,,
Ethical issues involving drug research in pregnant women make it difficult to perform studies that validate the use of analgesics during this period, which contributes to the undertreatment and a medical attitude of caution in this population group. According to the FDA, some medications are re-categorized according to gestational age or length of use as shown in [Table 2].,,
Undertreatment of this condition increases the risk of pain chronicity and disorders such as anxiety, depression, and hypertension, which have a negative impact on the outcome of delivery and women's quality of life during and after the gestational period.,,
It is estimated that half of women who have the first manifestation of low back pain during pregnancy present pain 1 year after delivery and 20% of them remain with symptoms for up to 3 years after delivery childbirth.,
As for pelvic girdle pain, despite being self-limiting in most cases and lasting about 6 months after delivery, 8%–10% of women with pain persist for 1–2 years., A study by Elden et al. confirmed that some factors associated with pain in pelvic girdle during pregnancy such as anxiety, depression, and mostly tests positive for pain at initial assessment contribute to long-term pain persistence, especially when associated with low back pain before pregnancy, leading to higher rates of mood disorders and catastrophizing pain, which perpetuates painful syndromes. However, this study had a small sample of pregnant women and found no relationship of other risk factors suggested in the literature as perpetuating of pain syndromes, such as BMI, hypermobility, type of work and absenteeism, mode of delivery,, high fetal weight, and number of hours of sleep.
Some risk factors are also associated. The mechanism of pain chronicity in pregnant women is not very well known; however, some references suggest as risk factors for pain chronicity: BMI during the period pre-/end-pregnancy, BMI at 6 months after delivery, presence of back pain before and during pregnancy, physically heavy work, older age, noneducation, unskilled work, high intensity of pain, low index of mobility, and high number of positive pain tests. Another study that followed pregnant women with low back pain for 3 years also suggested as contributing factors for the perpetuation of pain: reduced muscle endurance, measured for the back extensor muscles as well as for the hip abductor muscles, and increased movement in the pelvic joints.
The development of models for a multidisciplinary approach to chronic pain was based on the psychological and social factors, not only pathophysiological mechanisms and nociceptive factors as proposed beforee. This model showed cost-effectiveness because it reduced the need for medication and decreased morbidity to address various aspects of pain based on the biopsychosocial model.
Although some studies show little improvement in functionality and pain with multidisciplinary treatment compared to standard treatment for chronic low back pain in the general population (Skelly, 2020), other studies have shown moderate evidence for pain improvement with multidisciplinary rehabilitation (Davin, 2020; Karjalainen, 2003).
Although Liddle and Pennick's systematic review of 2015 showed little evidence of pain improvement in the use of isolated therapies for the control of low back pain and pelvic pain in pregnant women, there are still few studies that have analyzed the impact of multidisciplinary physical rehabilitation programs to reduce pain and risk of chronic musculoskeletal disorders during and after childbirth, probably due to the difficulty of standardizing the components of an interdisciplinary rehabilitation model and comparing them.
Our review evaluated two articles that used different multidisciplinary strategies to evaluate distinct impacts on pain. Both showed significant reduction in pain intensity.
In pregnant women, however, the methodology had some limitations: Beyaz et al. based their study on an adapted aerobic exercise program along with stretching, strengthening, relaxation, and breathing exercises performed under physiatrist supervision but they assessed only subjective parameters to assess pre- and post-intervention pain levels and didn't explore physical tests used in the clinical evaluation. The study by de George et al. set up a pain education, manual therapy and pelvic stabilization, and exercise program with weekly monitoring by the chiropractor in addition to obstetric follow-up and used more objective methods such as questionnaires and detailing the physical examination maneuvers used, which made the comparison parameters more reliable.
| Conclusion|| |
Despite the high prevalence of musculoskeletal disorders in pregnant women, there is still an undertreatment of pain in this population group. This is explained partly due to the limitations of pharmacological therapies and the low efficacy of nonpharmacological therapies.
Although the literature has well established the cost-effectiveness of using multidisciplinary approaches to chronic pain control and intervention in its perpetuating factors, there are no well-defined protocols for the application of these strategies in pregnant women, as shown by the scarcity of studies found in the literature.
Therefore, this reinforces the need for further studies with objective parameters to analyze the effectiveness of the multidisciplinary approach for the control of musculoskeletal pain and prevention of chronicity in pregnant women.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]