Physical Therapy and Pregnancy-Related LBP

PHYSICAL THERAPY INTERVENTIONS INCLUDING MANUAL THERAPY,

EXERCISE, AND PILATES IN THE MANAGEMENT OF A PATIENT WITH

PREGNANCY-RELATED LOW BACK PAIN

________________________________________________________________

A Case Report

Presented to

The Faculty of the Marieb College of Health and Human Services

Florida Gulf Coast University

In Partial Fulfillment

of the Requirement for the Degree of

Doctor of Physical Therapy

________________________________________________________________

By

Samantha T. Lovos

2017
Physical Therapy and Pregnancy-Related LBP

APPROVAL SHEET

This case report

is submitted in partial fulfillment of the

requirements for the degree of

Doctor of Physical Therapy

____________________________
Samantha T. Lovos

Approved: April 2017

____________________________
Arie van Duijn, EdD, PT, OCS
Committee Chair

______________________________
Rose M. Pignataro, PT, PhD, DPT, CWS, CHES
Committee Member

The final copy of this case report has been examined by the signatories, and we find
that both the content and the form meet acceptable presentation standards of scholarly
work in the above mentioned discipline.
Physical Therapy and Pregnancy-Related LBP

Acknowledgements

I would like to thank my family for their support throughout physical therapy

school. I would also like to thank Pat Curr, PT for her continued assistance and

dedication of time in order to make the completion of this case report possible. Lastly, I

would like to thank my committee members, Dr. Arie van Duijn and Dr. Rose Pignataro

for their continued guidance in completing this paper.

Physical Therapy and Pregnancy-Related LBP 1

Table of Contents

Abstract 2

Background and Purpose 4

Case Description 9

Patient History and Subjective 9

Clinical Impression 1 10

Examination 11

Clinical Impression 2 13

Intervention 15

Outcomes 23

Discussion 25

References 27
Physical Therapy and Pregnancy-Related LBP 2

Abstract

Background and Purpose: Developing low back pain while pregnant is very common.

Risk factors for developing pregnancy-related low back pain include pre-pregnancy

activity level, history of low back pain prior to pregnancy and during previous

pregnancies, and number of previous pregnancies. Exercise has been shown to lessen the

degree of pregnancy-related low back pain; however, many women still do not partake in

exercise while pregnant. The purpose of this case report is illustrate the effects of a

physical therapy treatment program that integrated Pilates in order to enhance treatment

outcomes in a pregnant female with low back pain. Case Description: The patient was a

34-year-old female that was 21 weeks pregnant with her fourth child. She presented to

physical therapy with recent onset of low back pain. This patient had a history of chronic

low back pain that had been managed well in the past with physical therapy. At the time

of the initial evaluation, the patient presented with bilateral radiating leg pain, reporting

intensity of low back pain and leg pain as 7 to 8/10. The patient reported having the

greatest difficulty with walking, transitional movements, sitting, standing, reaching,

twisting, lifting, and rolling in bed. Outcome measures included the modified Oswestry

Low Back Pain Disability Questionnaire and the numeric pain rating scale. Treatment

interventions included myofascial manipulation, body mechanics, muscle energy

techniques, joint mobilization, range of motion, Pilates core stabilization exercises, and

core strengthening exercises for a period of 7 weeks. Outcomes: The Modified Oswestry

score improved from 84% to 22%, and the numeric pain rating scale improved from 7 to

8/10 to 2/10. After completing five physical therapy treatment sessions, the patient

demonstrated an improved gait pattern and was able to return to work. Discussion: This
Physical Therapy and Pregnancy-Related LBP 3

case report has shown how a multi-modal physical therapy treatment that incorporated

manual therapy, core strengthening, and core stabilization using Pilates exercise was used

to decrease pain and improve function in a 34-year-old pregnant female with a one-week

history of acute low back pain. Further research is warranted to investigate the effects of

incorporating Pilates based exercises in the management of pregnancy related low back

pain.
Physical Therapy and Pregnancy-Related LBP 4

Background and Purpose

Low back pain is a common reason for lost workdays in the United States

(Freburger et al., 2009). Among females, there is a likelihood of developing back pain

while pregnant. It is a very common issue; in fact, one study showed that 68.9% of

women experienced back pain during pregnancy (Wang et al., 2004). In a review

conducted by Sabino and Grauer (2008), researchers reported that about 10% of pregnant

women claim that the low back pain has prevented them from working, and another 80%

reported that the low back pain has affected their daily lives.

There are many musculoskeletal changes that occur during pregnancy. According

to Foti, Davids and Bagley (2002), during pregnancy, there is a decrease in abdominal

muscle strength due to overstretching in order to compensate for the expansion of the

uterus. Their research also mentioned common problems of low back pain (lumbosacral

and SI joint), carpal tunnel syndrome, leg cramps, and hip pain, which can arise during

pregnancy. These problems do exist, but according to Gutke, Ostgaard, and Oberg (2008),

it is unknown whether muscular dysfunction were long standing pre-pregnancy problems,

or whether women were experiencing muscular dysfunction early in pregnancy.

Another musculoskeletal change during pregnancy is posterior displacement of

the center of gravity (Opala-Berdzik, Bacik, Cieslinska-Swider, Plewa, & Gajewska,

2010). This is primarily because of the increased weight in the abdominal region. The

authors of the previous study speculated that this posterior displacement might also be a

physiological factor because the women may change their postural alignment in order to

prevent forward falling, risking injury to the unborn child. This posterior displacement

may also put excess stress on the back leading to back pain (Opala-Berdzik et al.).
Physical Therapy and Pregnancy-Related LBP 5

There are many risk factors that are associated with developing low back pain

during pregnancy. Many of these risk factors are modifiable and within the woman’s

personal control. One such modifiable risk factor is pre-pregnancy activity level. Other

risk factors include previous history of lumbar problems or chronic back pain, and

number of previous pregnancies. A literature review conducted by Sabino and Grauer

(2008) found that individuals who held more physically demanding or strenuous careers

were more likely to develop back pain during pregnancy. Women who had a previous

history of low back pain had a higher prevalence of experiencing back pain during

pregnancy as compared to women who have no pre-existing history. In addition,

according to a study performed by Al-Sayegh et al. (2012), women who have had low

back pain during previous pregnancies were at an increased risk of developing low back

pain during subsequent pregnancies when compared to women who were experiencing

their first pregnancy.

Typical health benefits of exercise are well documented, and many of these

benefits are likely to apply during pregnancy, as well as in other stages of life. Some

of the health benefits for exercising during pregnancy include maintenance of

physical fitness, weight management, and enhanced physical well being. A review

conducted by Horak and Osman (2012) reported that pregnant women who exercise

are less likely to experience stress, anxiety, and depression. This review also found

that exercise could alleviate other symptoms associated with pregnancy such as

fatigue, swelling of the extremities, constipation, and heartburn. The benefits of

exercising while pregnant are well known and documented, however, a literature

review by Gaston and Cramp (2011) found that the rate and duration of exercise
Physical Therapy and Pregnancy-Related LBP 6

from pre-pregnancy to pregnancy decreases, and few women meet the

recommended pregnancy exercise guidelines. The American Congress of

Obstetricians and Gynecologists (ACOG) (2015) recommends physical activity in

all stages of life, including those who are pregnant. ACOG has developed a list of

relative contraindications to exercise that includes: severe anemia; unevaluated

maternal cardiac arrhythmia; chronic bronchitis; poorly controlled type 1 diabetes;

extreme morbid obesity; extreme underweight (BMI <12); history of extremely

sedentary lifestyle; intrauterine growth restriction in current pregnancy; poorly

controlled hypertension; orthopedic limitations; poorly controlled seizure disorder;

poorly controlled hyperthyroidism; and heavy smoking (2015). However, there are

some absolute contraindications for exercising while pregnant. According to ACOG,

absolute contraindications for exercising during pregnancy include:

hemodynamically significant heart disease; restrictive lung disease; incompetent

cervix; multiple gestation at risk of premature labor; persistent second or third

trimester bleeding; placenta previa after 26 weeks of gestation; premature labor

during current pregnancy; ruptured membranes; preeclampsia or pregnancy induced

hypertension; and severe anemia (2015).

In numerous studies, exercise has been shown to reduce the intensity of back pain

(Garshasbi &Faghih Zadeh, 2005; Keskin et al., 2012; Peterson, Haas, & Gregory, 2012;

Eggen, Stuge, Mowinckel, Jensen, & Hagen, 2012). A review conducted by Horak and

Osman (2012) reported that improving posture and body mechanics during pregnancy

through exercise reduced the incidence and severity of low back pain. Some of the

exercise programs used in these studies included pelvic tilts, gluteus maximus, latissimus
Physical Therapy and Pregnancy-Related LBP 7

dorsi, abdominal, and hamstring strengthening, as well as postural exercises and general

instruction from a physical therapist (Peterson, Haas, & Gregory, 2012; Garshasbi &

Faghih Zadeh, 2004; Keskin et at., 2012; Eggen et al., 2012). Most studies included

exercises that focus on strengthening the core muscles. Most of the studies included

subjects from different trimesters during their pregnancy; however, no matter what

trimester the exercise program was started, the exercises focused on core strengthening

and stability. Differences between the studies included intensity of low back pain at onset.

It is important to note that low back pain during pregnancy usually increases as the

pregnancy progresses (Yan, Hung, Gau, & Lin, 2014). Therefore, among research

participants, women who started exercising during a later trimester could have exhibited

higher self-reported intensity levels of back pain at baseline. Nonetheless, results show

that exercise focusing on core strength and stability at any point during the pregnancy is

beneficial in reducing the intensity of back pain. In most cases, women have different

intensities of back pain at different times throughout the pregnancy, so implementing and

maintaining an exercise program focused on core strength and stability during the

duration of the pregnancy may be the best solution in managing back pain.

Pilates is a form of exercise that can be performed with the use of specialized

equipment, or it may be mat based. The specialized equipment that can be used includes

trapeze table, reformer, springboard, chair, Pilates arch, and ladder barrel. A review

conducted by Wells, Kolt, and Bialocerkowski (2012) defined Pilates as a mind-body

exercise that requires core strength, posture, flexibility, and attention to postural muscle

control and breathing. Joseph Pilates founded Pilates exercise in the 1920s. There are six

traditional principles of Pilates: centering (tightening the muscular center of the body),
Physical Therapy and Pregnancy-Related LBP 8

concentration (cognitive attention required to perform the exercises), control (close

management of posture and movement during exercise), precision (performing the right

movements each time), flow (smooth transition of movements), and breathing (moving

air into and out of the lungs in coordination with exercise) (Wells et al., 2012). Modern

Pilates uses Joseph Pilates’ philosophy and modified principles (Latey, 2001). Initially,

with modern Pilates, the emphasis is on understanding the body and improving awareness,

connecting breathing, and getting a feel of the right muscles working. With modern

Pilates, the exercises are always tailored to the needs of the individual client.

While studies regarding the benefits of Pilates for the management of low back

pain can be found in the literature, research specific to its use for low back pain during

pregnancy is scarce. Prior studies have shown that weakened muscles, such as the

transversus abdonimis, may be responsible for decreased spinal stability and thus, the

onset of low back pain (Hodges & Richardson, 1996). A systematic review conducted by

Posadzki, Lizis, and Hagner-Derengowska (2011) found that, although many articles

claimed that Pilates improved low back pain, the sample sizes of these studies were small,

making it difficult to generalize the meaning of the results. A survey of Pilates trained

physical therapists reported some potential indications for the use of Pilates exercise in

individuals with poor body awareness and maladaptive movement patterns (Wells, Kolt,

Marshall, & Bialocerkowski, 2014). Some of the potential benefits found in this previous

study included an increase in functional ability for individuals with chronic low back pain,

as well as improved body awareness, posture, and movement patterns.

While there are numerous research articles available that demonstrate the

effectiveness of exercise in the management of low back pain, many women continue to
Physical Therapy and Pregnancy-Related LBP 9

reduce or eliminate exercise altogether when they become pregnant. Pilates has been

shown to be effective in the management of chronic low back pain in the general

population, but limited research has been conducted on the pregnant population. Given

the match between the proposed benefits of Pilates and the physical impairments

commonly encountered during pregnancy, it is likely that this intervention can provide

significant benefits within this population. Therefore, the purpose of this case report is

illustrate the effects of a multi-modal physical therapy treatment program that integrated

Pilates in order to enhance treatment outcomes in a pregnant female with low back pain.

Case Description

Patient History and Systems Review

The patient was a 34-year-old female that was 21 weeks pregnant with her fourth

child. The patient has a BMI of 32.1. Prior to initial evaluation, the patient was seen by

her primary care physician where she was examined and given a referral for physical

therapy, since she physical therapy had been previously successful in addressing the

patient’s chronic low back pain prior to pregnancy. At the time of the initial evaluation,

the patient presented to the outpatient physical therapy clinic with reports of low back

pain along with bilateral radiating leg pain, right leg pain greater than left leg pain. The

radiating pain in the patient’s bilateral lower extremities did not follow a dermatomal

pattern. The patient reported pain in the posterior aspect of each leg. The patient reported

that the issues began approximately one week prior to seeking the physical therapy

consult: she was bending forward to pull on slacks, her back “locked up,” and she

reported acute onset of severe low back pain with bilateral leg pain. The patient reported

intensity of her initial pain as 8/10 using the numeric pain rating scale. At the time of the
Physical Therapy and Pregnancy-Related LBP 10

evaluation, the back pain had decreased slightly to 7/10. Since this incident, the patient

was unable to return to work as a neonatal intensive care unit (NICU) nurse, or perform

her usual childcare/household responsibilities. She reported the greatest difficulty with

walking, transitional movements (sit to stand), sitting, standing, reaching, lifting, twisting,

and rolling in bed. The patient’s previous medical history includes a large focal central

disc protrusion at L5-S1, and an annular fissure at L4-L5 with moderate bulging disc, and

chronic right-sided low back pain with sciatica. Other co-morbidities included anxiety

disorder, hypothyroidism, IBS, and premature atrial contraction. This patient’s surgical

history includes caudal epidural steroid injections. The medications the patient was taking

at the time of evaluation and treatment included synthroid and a prenatal multivitamin.

Prior to acute onset of low back pain with lower extremity radiation, the patient

reported no trouble performing activities of daily living or her usual occupational

activities. These occupational activities included standing for extended periods of time

and bending over an incubator caring for her infant patients. The patient did not report

any recreational activities that she would like to resume, but her primary functional goals

included the ability to return to cooking, cleaning, and taking care of her children, as well

as being able to return to work as a NICU nurse.

Clinical Impression 1

The patient was a 34-year-old female, 21 weeks pregnant with her fourth child.

This patient had a history of chronic low back pain, presenting to physical therapy after

recent exacerbation. The patient presented with increased level of pain both in the low

back and bilateral lower extremities, preventing this patient from working and performing

her usual household duties.

Physical Therapy and Pregnancy-Related LBP 11

The differential diagnoses for this patient included acute low back pain, lumbar

instability, sacroiliac dysfunction, and transient osteoporosis. Transient osteoporosis can

result in back, hip, groin, or lower extremity pain (Boissonnault & Boissonnault, 2005).

However, this patient’s location of pain is not consistent with the diagnosis of transient

osteoporosis. Further test and measures planned include postural assessment, palpation,

gait assessment, and active range of motion. Based on the patient’s history, the ICF

classifications that this patient may fit into include: acute low back pain with movement

coordination impairments, acute low back pain with mobility deficits, and acute low back

pain with radiating pain. This patient is a good candidate for this case report due to her

number of previous pregnancies, previous history of low back pain with successful

physical therapy management, and the recurrence of this back pain during pregnancy.

Examination

During the initial evaluation of the patient, standard outcome measures were

assessed and objective data were obtained. The patient filled out a self-reported outcome

measure, the Modified Oswestry Low Back Disability Questionnaire, and reported her

pain level using the numeric pain scale. The pain level the patient reported was a 7/10

and her calculated score on the Modified Oswestry was 84%. The Modified Oswestry is a

questionnaire that consists of ten questions pertaining to the effect the low back pain has

on the individual completing daily tasks/activities. Each question is scored on a scale of 0

to 5, with higher values reflecting greater the disability (Fritz & Irrgang, 2001). The total

score is then converted to a percentage, with higher percentage indicating greater

disability. The previous study found that the test-retest reliability of the modified

Oswestry questionnaire is .90 (intraclass correlation coefficient) with a 95% confidence

Physical Therapy and Pregnancy-Related LBP 12

interval of 0.78 to 0.96. These authors also reported that the minimum clinically

important difference for the modified Oswestry questionnaire is 6 percentage points. The

patient denied any bowel or bladder symptoms, or indications of cauda equina syndrome.

The patient also reported her level of pain based on the numeric pain rating scale. The

numeric pain rating scale is an 11-point scale ranging from 0 to 10. A rating of 0 means

the patient does not have any pain, and a score of 10 means the pain is severe. According

to a study performed by Childs, Piva, and Fritz (2005), the minimally detectable change

for the numeric pain scale is 2 points with a 95% confidence interval.

The initial evaluation also included postural assessment and palpation of soft

tissue and bony landmarks. It was found that the patient had an anteriorly rotated right

ilium and the sacrum was side bent left and rotated left. However, these findings should

be interpreted with caution based on prior research regarding validity and reliability of

diagnosis based on manual palpation of pelvic asymmetries. Kilby, Heneghan, and

Maybury (2011) examined the validity of manual palpation of the PSIS of the pelvis.

This study reported the mean error for PSIS palpation was 20.07mm and 20.59mm for

left and right PSIS palpation. This study concluded that the validity of manual palpation

may not be acceptable when it comes to assessing pelvic symmetry. A study conducted

by Holmgren and Waling (2008) examined the inter-examiner reliability of static

palpation tests used to assess pelvic dysfunction. This study found that the reliability was

poor for these locations. It was also noted that the patient had increased muscle tension in

the quadratus lumborum and piriformis bilaterally. Upon palpation of the lumbar spine,

the physical therapist noted that the patient’s L5 spinous process was difficult to palpate,

as though there was a slight spondyolisthesis. Gait assessment was significant for an
Physical Therapy and Pregnancy-Related LBP 13

antalgic gait pattern, including bilateral decreased weight shifting, decreased step length,

and a very slow cadence. Active range of motion of the patient’s lumbar spine was

assessed using a tape measure starting at the spinous process of L1 going to the spinous

process of S1. The patient was then asked to forward bend and the distance of change

was measured at 4 cm. Next the patient was asked to backward bend this measurement

was 0 cm. Finally, the patient was asked to side-bend to the left and then to the right. This

measurement was assessed by first lining the tape measure up with the patients 3 rd digit,

as the patient side bends the examiner takes note of the distance the 3 rd digit traveled. For

right and left side bending the patient recorded distances of 17cm and 18cm, respectively.

This patient demonstrated decreased active range of motion for both flexion and

extension movements of the lumbar spine. A measurement of 6cm and 1.6cm are

considered normal for lumbar flexion and extension, respectively (Norkin & White,

2009). Both left and right side bending values for this particular patient indicates a

decrease in range of motion, with a measurement of 21cm being consider normal for

lateral bending. Following the above-mentioned test and measures, the patient was in a

great deal of pain, so the evaluation concluded.

Clinical Impression 2

At the conclusion of the initial examination, the physical therapist determined that

the patient was experiencing acute pregnancy related low back pain. Given a history of

low back pain prior to pregnancy, this patient was at increased risk for experiencing back

pain while pregnant. However, her prognosis was good, based on previous ability to

successfully manage prior episodes of low back pain by using conservative measures.
Physical Therapy and Pregnancy-Related LBP 14

The problem list for this patient included myofascial and soft tissue restriction,

pain, and range of motion impairments. Table 1 summarizes all evaluation findings.

According to Olson (2009), signs and symptoms of low back instability include referred

pain to the buttock or thigh, paraspinal muscle guarding, and pain with sustained postures.

This particular case patient demonstrated many of these signs. This patient’s examination

findings are consistent with the ICF classification of acute low back pain with movement

coordination impairments. The short and long term therapy goals established with the

patient are depicted in table 2. The patient’s overall goal was to manage the pain during

her pregnancy and return to work.

Physical Therapy and Pregnancy-Related LBP 15

Intervention

Including the initial evaluation, the patient received a total of 12 physical therapy

visits consisting of 45-minute sessions, twice a week for 7 weeks. The interventions that

were planned with this patient included myofascial manipulation, instruction in proper

body mechanics, muscle energy techniques performed to correct the anteriorly rotated

ilium, lumbar grade 2 joint mobilizations for pain control, range of motion, Pilates based

core stabilization, and strengthening. The first treatment session consisted of myofascial

manipulation, education on body mechanics, muscle energy techniques, and lumbar joint

mobilizations. The range of motion exercises began on the second visit. As the patient

progressed through treatment the Pilates based core stabilization and strengthening,

exercises were added. The Pilates exercise performed over the course of this patient’s

treatment included mat and chair exercises. The Pilates exercises were employed with the
Physical Therapy and Pregnancy-Related LBP 16

goal of improving postural awareness and core strength and stability. Initially, the patient

would arrive to the therapy treatment sessions requiring muscle energy techniques and

joint mobilizations to the sacroiliac joint. These techniques were required due to the

appearance of an anteriorly rotated ilium and left side bent and rotated sacrum. During

the course of physical therapy treatment, the patient purchased an SI belt in order to help

stabilize the joint by providing compression to the sacroiliac joint, especially on return to

work. In a systematic review conducted by Sharma, Sharma, Steiner, and Brudvig (2014)

found that the use of a SI belt and stabilization exercises has been shown to be the most

beneficial interventions for the pregnant population. The placement of the SI belt is an

important factor in the treatment of this patient population. If the SI belt is to be used for

stability, it should be placed at the level of the anterior superior iliac spine. Once the

patient began wearing the belt, the muscle energy techniques and sacral mobilizations

were no longer needed. She also began experiencing less pain throughout the workday.

At the beginning of this patient’s treatment, the patient appeared to have an

anteriorly rotated right ilium. To address this, the physical therapist performed a muscle

energy technique during the first four visits. The muscle energy technique was similar to

the one used in the Selkow, Grindstaff, Cross, Pugh, Hertel, & Saliba (2009) study. In the

previous study the MET technique that was used was as follows: the leg of the anterior

innominate was placed over the examiner’s shoulder, and the leg of the posterior

innominate was placed under the examiner’s hand. When an isometric contraction is

produced, the anterior innominate will rotate posteriorly from the force of the hamstrings,

and the posterior innominate will rotate anteriorly from the force of the iliopsoas.
Physical Therapy and Pregnancy-Related LBP 17

The only difference in the current case report was that the patient performed the

technique without the assistance of the physical therapist. The patient was instructed to

cross her right leg over left, pushing down with her right leg and pulling up with her left

leg, activating her right hip extensors and left hip flexors 5 times, holding for 10 seconds.

By activating the right hip extensors and left hip flexors, the patient is essentially using

her hip extensors to pull the ilium into the proper position. The patient was also instructed

in self-assessment and self- management techniques to perform when necessary.

Initially, the patient also presented with a left side bent and rotated sacrum. To

address this issue, the therapist performed grade 2 sustained sacral mobilizations. To treat

the left rotated sacrum, the therapist had the patient lie prone, with pillows built up

around the abdomen so the patient was not directly lying on her stomach. The patient’s

right lower extremity was placed into external rotation, and the left lower extremity was

internally rotated. The therapist then stood on the right side of the patient with her right

hand on the posterior aspect of the left inferior lateral angle. The therapist’s left hand was

placed over the right PSIS. The physical therapist then applied a posterior to anterior

force to the left ilium using her right hand, while using her left hand to apply an anterior

to lateral force to the right ilium for stabilization. In order to treat the left side bent

position, the therapist had to perform another mobilization. The patient was still lying

prone with pillows built up around her abdomen. The therapist stood on the patient’s left

side and placed the thenar aspect of her right hand on the inferior aspect to the right

inferior lateral angle. Force was then applied in a lateral direction to the inferior aspect of

the right inferior lateral angle (Paris, Nyberg, & Irwin, 1993).
Physical Therapy and Pregnancy-Related LBP 18

The sequence of Pilates chair exercises performed is depicted in Figure 1. The

Pilates mat exercises included diaphragmatic breathing and diaphragmatic breathing with

leg fallouts. Each of the Pilates exercises was performed for eight repetitions each. Wells,

Kolt, Marshall, and Bialocerkowski (2013), conducted a survey of Pilates trained

Australian Physical therapists and found that there was 100% agreement that Pilates

sessions should last about 30 to 60 minutes. For this case report, the use of eight

repetitions was employed due to the number of Pilates exercises performed during the

session, ultimately amounting to about 30 minutes each session. The Pilates chair

exercises were preformed to improve postural awareness, core strength, and leg strength.

The leg muscles that were targeted during the Pilates chair exercises were the gluteus

maximus, gluteus medius, and hip extensors. The hip extensors were strengthened

eccentrically during this activity. The patient also performed traditional strengthening

exercises targeting gluteus maximus and gluteus medius. When performing these

strengthening exercises, the principles of Pilates were still utilized, such as breathing and

stabilization of the spine prior to movement.

Physical Therapy and Pregnancy-Related LBP 19
Physical Therapy and Pregnancy-Related LBP 20
Physical Therapy and Pregnancy-Related LBP 21

Throughout the course of the therapy, the patient participated in a home exercise

program, which was continuously updated based on response to treatment and changes in

the patient’s ability. The patient demonstrated and verbalized understanding to this home

exercise program. The patient was also continually educated on the importance of proper

posture and body mechanics while performing her daily activities. Table 3 depicts an

outline of the progression of treatment interventions utilized in the patient’s plan of care.
Physical Therapy and Pregnancy-Related LBP 22

Table 3
Progress of Interventions

Initial Visit 2 (3 days) Visit 3 (5 days) Visit 4 (6 days)

Evaluation/
Treatment

- QL release - Visit 1 - Visit 1 and 2 - Visit 1, 2 and 3

- Piriformis exercises exercises exercise
release - STM with - Diaphragmatic - 2 way ball/belt *
- Sacral stone to breathing
mobilizatio thoracic and - Leg fall out
n lumbar - Heel slides
- Thoracic spine
and - Left leg
Lumbar lengthener
mobilizatio - Standing
n (PA and back
rotation) extension
- MET - Slide glides
anterior to L•
right
rotation
Visit 5 (10 Visit 5 (10 Visits 7 (19 days) and 8 (21 days)
days) days)
- Left leg - Leg fall out - Visit 6 exercises
lengthener - Heel slides
- Diaphragm - 2 way
atic ball/belt*
breathing - clam shell
- Leg fall out (Moderate
- Clam shell resistance)
- 2 way - glute sets
ball/belt* standing
- Glute set - side lying
standing abduction
- Heel slides - glute set
with
contralateral
shoulder
extension
and limb on
step (Light
resistance)
Physical Therapy and Pregnancy-Related LBP 23

Table 3-Continued
Progress of Interventions

Visit 9 (28 days) Visit 10 (31 days) Visits 11 (39 days)

and 12 (47days
- Visit 1 exercises - Visit 9 exercises - Dead bug (with
- Clam shell (Moderate excluding visit 1 wedge behind
resistance) - Dead bug (with wedge back)
- glute set with behind back) - Side lying leg
contralateral shoulder - Side lying leg lifts lifts
extension and limb - Side lying leg circles - Side lying leg
on step (Light - Pilates chair series circles
resistance) - Pilates chair
- Step up with series
contralateral shoulder
extension
- Standing shoulder
extension with red
band
Note. QL: Quadratus Lumborum; PA: Posterior Anterior; MET: Muscle Energy
Technique; STM: Soft tissue massage.
*2-way ball/belt exercise: Place a ball between knees and belt around knees. Push out
against the band with outer legs while tightening pelvic floor muscles and transverse
abdominis and hold. Then gently squeeze ball while tightening pelvic floor muscles and
transverse abdominis and hold.
• Slide glides: The patient stands against a wall, with one side away from the wall. The
feet of the patient are placed approximately shoulders width apart. The patient then leans
her shoulder against the wall; the other hand is placed on the patient’s hip providing a
lateral force at the hips in the direction of the wall. This is held for about 3 seconds then
slowly released. This is repeated for 10 repetitions.

Outcomes

Over the course of this patient’s treatment sessions, she reported decreased pain

and noted that she was walking better. Two modified Oswestry questionnaires were

administered to the patient throughout the course of her treatment. The first modified

Oswestry questionnaire was completed at initial evaluation, and the second modified

Oswestry questionnaire was completed on the 11th visit. Her score improved from an

84% to a 22%. The patient improved her level of disability secondary to her back pain
Physical Therapy and Pregnancy-Related LBP 24

from severe to a moderate level of disability. This patient still experienced the most pain

with the following activities: standing, sitting, and traveling. Throughout her treatment,

the patient’s pain decreased from consistent pain, with peak level of 8/10 to occasional

2/10 pain levels. After completing 5 sessions of therapy, the patient was released to return

to work. During the course of physical therapy treatment, the patient also participated in

several family outings, including a beach day and a family vacation. The patient was also

able to self manage her pelvic asymmetries, no longer requiring sacral mobilizations or

muscle energy techniques by the 5th visit. The patient was also able to maintain and self-

manage her anteriorly rotated ilium. Table 4 depicts the patient’s initial and follow up

outcome measure scores.

No additional testing was performed because the patient did not return to physical

therapy after her vacation. She did report via phone conversation that she was feeling

much better and needed to cancel her last appointment. One month following self-

discharge, the patient called the therapist to resume treatment secondary to increasing low

back pain. However, the therapist was unable to see the patient quickly and referred her

to another therapist.
Physical Therapy and Pregnancy-Related LBP 25

Discussion

This case report has shown how an exercise based physical therapy plan of care

that incorporated manual therapy, core strengthening, and core stabilization using Pilates

exercise was used to rehabilitate a 34-year-old pregnant female with a one-week history

of acute low back pain. This patient did have a history of chronic back pain prior to

becoming pregnant, which is a risk factor for developing back pain during pregnancy.

ACOG guidelines recommend exercising while pregnant; however, many women do not

follow this guideline. In the literature, numerous studies have shown that exercise can

reduce the intensity of back pain while pregnant (Garshasbi & Faghih Zadeh, 2005;

Keskin et al., 2012; Peterson, Haas, & Gregory, 2012; Eggen, Stuge, Mowinckel, Jensen,

&Hagen, 2012). The exercises found in the literature included body mechanics, core

strengthening, stability, and postural exercises.

This patient demonstrated instability in her lumbopelvic region. On several

occasions the patient would present for treatment with a right anteriorly rotated ilium. In

the literature muscle energy techniques for lumbopelvic pain have been shown to reduce

pain levels, and thus, it is an appropriate treatment prior to stabilization and strengthening

exercises (Selkow, Grindstaff, Cross, Pugh, Hertel, & Saliba, 2009). As the patient

progressed through physical therapy and was able to maintain pelvic alignment, her pain

levels decreased. For this patient, following the muscle energy technique, the core

stabilizers were targeted, especially transverus abdominis, as it has been shown in the

literature to reduce the laxity of the sacroiliac joint (Richardson et al., 2002). Consistent

with previous research, this patient benefited from core stabilization and strengthening

exercises.
Physical Therapy and Pregnancy-Related LBP 26

Pilates targets the core while incorporating improved kinesthetic awareness

during functional movement patterns. In this case study, the patient also showed

improvement during the course of her treatment, consistent with prior research on

exercise and low back pain in pregnancy. However, it should be noted that evidence

specifically reflecting the efficacy of Pilates treatment on chronic low back pain

demonstrates conflicting results, and there is little to no research pertaining to the

treatment of low back pain with Pilates in the pregnant population. Future studies should

include larger sample sizes, as well as methods analyzing the effectiveness of exercise

including Pilates in the treatment of pregnancy-related low back pain. This case patient

demonstrated improvement over the course of her treatment, supporting use of manual

therapy, core strengthening, and Pilates core stabilization exercises in the treatment of

pregnancy related low back pain.

Physical Therapy and Pregnancy-Related LBP 27

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