LBP in Pregnancy: OMT for the MD

1. LBP in Pregnancy:OMT for the MD Capt. James J Arnold D.O. Family Physician Andersen AFB, Guam March 15th 2007

2. Objectives • Background Facts • Case • Review the standard approach to LBP in PG • The Pathology and Physics causing LBP in PG • How OMT can help • Demonstration and teaching of an OMT regiment any doc can use

3. Background • 50% of all pregnant women will experience back pain. (41% of those woman are experiencing back pain for the first time) • More common in women with preexisting back pain, back pain in a previous pregnancy, advanced maternal age, and multiparity • Height, weight, race, fetal weight, and socioeconomic status do not appear to be risk factors • Can occur anytime in pregnancy, but obviously much more prevalent in the second half of pregnancy and worsens until delivery • Pain usually worsens with activity and improves with rest • 80-95% of the time, back pain resolves post-partum

4. Case • 29 yo G1P0 female at 34 weeks gestation with lumbo-sacral pain for 4 weeks • Denies any radicular symptoms • Pain getting worse with each week of pregnancy • PE shows TTP of paraspinal muscles (L=R) and pain along the right SI joint • What is you’re A/P?

5. Standard of Care • Lumbago treatment per ACOG • Tylenol • Wear low-heel (but not flat shoes) with good arch support • Get help when lifting heavy objects • Firm mattress better then soft • Good Mechanics: squat down, bend knees and keep back straight when lifting • Use chairs with good back support, or use small pillow • 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 pressure • Sleep on side with pillow between knees or under belly for support • Heat/Cold Therapy • Stretches/Exercise/Self-PT – flexion exercises to strengthen abdomen, extension exercises to strengthen paraspinal muscles • Other known therapies include support belts, water therapy, acupuncture

7. Standard of Care • Radicular Symptoms/HNP • If pain only, without Neuro deficit, then same as above. • If significant pain not responding to conservative therapy, then consider imaging (MRI preferred). Epidural Steroid Injections are acceptable for HNP in PG • If progressive neuro-deficits, bladder/bowel dysfunction then disc surgery can be considered, but ideally not done until post-partum • C-section only if usual indication (i.e. FTP, Fetal Distress) exists, but an operative vaginal delivery may be helpful in reducing intrathecal pressures

8. Pathology of LBP in Pregnancy • The enlarged uterus causes a change in weight distribution • With ligamentous attachments to the sacrum, the uterus increases sacral tilt and subsequently lumbar lordosis • The weakening and separation of the abdominal muscle (diastasis recti) further allow for the above changes • Obviously this puts an added strain on the paraspinal muscle, SI joints, vertebral facets, and lumbar discs

9. To further complicate things…. • Relaxin does not discriminate • Relaxes the ALL and PLL of the lumbars • Increase SI mobility • Relaxin, however, helps make OMT easy

10. How OMT can help • Use in conjunction with the standard of care!! • What OMT Accomplishes • Decrease Lumbar Lordosis • Mobilizes Lumbars • Mobilizes SI joint

11. Current Literature • Several studies in the OMT literature show a 50% reduction in symptoms per subjective analysis. • Strong emphasis on treating SI dysfunction • Strong support for decreasing lordosis • Mobilizing lumbars is well supported in the allopathic literature for regular low back pain • Small study shows significant improvement in SI pain • Improvement on MAS, PTD, but no change on C-section rate seen on retrospective analysis • Prospective Trial in the works

12. OMT for MD’s: Regiment for LBP in Pregnancy • A regiment that is very similar to the one most DO’s use • Can use at every ROB visit where LBP is an issue • Very safe and requires no osteopathic diagnosis • Addresses the dysfunctions common to all PG pts with LBP • The Treatment Plan: • Stretch the Hamstrings • Frog Leg Technique • SI Mobilization • Chicago Roll • Extra Stuff • Killer Fingers – for HA’s • Pedal Pumps – for LE edema

13. Stretch the Hamstrings • Hamstrings originate from the pelvic rami and insert to the posterior femur, so if they are tight lumbar lordosis is further increased • Also, a good hamstring stretch also stretches the paraspinal muscles and the quadratus lumborum on the side your treating • Muscle Energy Technique – by stretching the muscle you inhibit the Golgi-tendon Reflex and as the muscles stretch they will relax and therefore lengthen

14. Stretch the Hamstrings • The technique (one side at a time): • With pt supine, flex hip to 90 degrees and extend knee until resistance is felt • Support the leg by holding the ankle with one hand and use the rest of your body as a wall that the pt will push off of • Have pt attempt to flex knee and bring there leg down pushing against you for 3-5 seconds, then relax • Once relaxed, take the patients leg to the new point of resistance and repeat the above 2 more times for a total of 3 reps • At the end of the 3 rep, take the pts leg to new point of resistance, then slowly lower leg back down to the table • Do the same to the other side!!

15. Frog Leg Technique • This technique is essentially a muscle energy technique • By pulling caudal traction on the sacrum the paraspinal muscle and the ligaments of the lumbo-sacral spine get stretched • This causes a decrease in lumbar lordosis

16. The Frog Leg Technique: • With the pt supine, have the pt assume the frog-leg position. The same exact position you use for a cervical check • Position your hand under the patient’s pelvis and cup the sacrum so you can pull caudally. • Have the pt take a deep breath in and as they exhale extend their legs straight. You will be able to pull the sacrum caudally during leg extension • Have the patient bring their legs back to the frog leg position, but as they do so maintain traction preventing the sacrum from moving cephlad • Repeat the above 2more times for a total of 3 reps

17. SI Mobilization • By mobilizing the SI joint, you can relieve pain at the joint • In SI dysfunction, the sacrum is seated unevenly in the SI joint • This is an articulatory technique that takes the SI joint through its full range of motion allowing it to reset self evenly back into the SI joint • DO’s are able to make very specific sacrum diagnosis’ allowing them to treat only one side (the affected side) and be complete in their treatment. • I am encouraging the MD’s to treat both sides, so no matter what the dysfunction, it will likely be treated (treating an unaffected side will not cause any harm to the patient, if the technique is done appropriately)

18. The SI Mobilization Technique: • Place the patient in the lateral Sims position: pt laying on their side with their torso turned towards the table (hugging the table); knees slightly flexed. The SI joint you are treating will be towards the ceiling • Get behind the pt and take your cephlad hand and place it on the sacrum to stabilize it • Take your caudal hand and reach over and grab the pt’s knee closest to the ceiling • Have the pt inhale as you bring the hip into full flexion • Then have the pt exhale while fully externally rotating the hip and then extend the leg • Repeat 3 times • You will likely feel an articulation of the SI with your stabilizing hand during the first rep • Do the same on the other side!!

19. Chicago Roll • Mobilizing the lumbars relieves pain at the affected level by allowing the paraspinal muscles and nerves attached to lay evenly without being stressed • This is an articulatory technique; by taking the lumbar through their range of motion the disc spaces will gap and lumbars rotated out of place will “pop” back into place • To be performed twice, once from each side of the table

20. The Chicago Roll Technique: • With the pt supine, have them interlace their fingers behind their neck with you standing on either side of the table • Hook your cephlad forearm under their arm opposite from you and take your caudad hand and stabilize the opposite ASIS • With one motion, use your cephlad arm to lift the pt’s torso up and over toward your side of the table • If any lumbars are rotated away from you, there will be articulations at that level • Repeat above from opposite side!!

21. Coding • For the DO’s (Need to document specific diagnosis and level (ie LonL Sacral Torsion, L4 RrSr) • 739.3 – Lumbar SD • 739.4 – Sacral SD • 739.5 – Pelvic SD • 739.6 – LE SD • CPT Codes – 98925 (1-2 body regions), 98926(3-4), 98927(5-6), 98928(7-8), 98929(9-10) • For the MD’s • Lumbago 724.2 • SI Pain 739.4 • CPT Codes – sorry MD’s, you can’t code for these without being a DO. But the satisfaction of making your patient feel better should be rewarding enough

22. Take Home Points • Use OMT in conjunction with standard of care (Our friend, Tylenol, behavioral modifications, home exercises) • Goals of treatment are to decrease lordosis, mobilize the SI’s, and mobilize the lumbars • Stretch Hamstrings, Frog Leg, SI mobilization and Chicago Roll at every ROB visit with a complaint of LBP • Cure = Delivery (usually) • Difficult cases or other concerns, refer to a DO colleague

23. References • My Education from Des Moines University • Thanks to Dr. David Boesler, DO. • Bermas, Bonnie; Changes to the musculoskeletal system during pregnancy; UpToDate.com, 2006. • Daly JM, Frame PS, Rapoza PA; Sacroiliac Subluxation: a common, treatable cause of low-back pain in pregnancy; Family Practice Research, June 1991. • Gunnar BJ; A Comparison of Spinal Manipulation with Standard Care for Patients with Low Back Pain; New England Journal of Medicine, November 1999. • Issacs, Brandon; Treatment of Back Pain in Pregnancy: A Simple Osteopathic Protocol; Paper for the Saint Louis University Dept of Family Medicine, 2000. • King, Hollis H; Osteopathic Treatment in Prenatal Care: A Retrospective Case Control Design Study; Journal of the American Osteopathic Association, December 2003. • Rath, Jean Duffy; Low Back during Pregnancy: Helping Patients take Control; The Journal of Musculoskeletal Medicine, April 2000. • Wang SM, Dezinno P; Low Back Pain during Pregnancy: Prevalence, Risk Factors, and Outcomes; Green Journal, July 2004.