4-Whitcomb Greg-The Biomechanics of Pregnancy · 2015-04-13 · Greg L. Whitcomb, BS, DC The...

Greg L. Whitcomb, BS, DC The Biomechanics of Pregnancy: Rehabilitation and Post‐Partum Care

Gestational Biomechanics & Axial Pain

New Perspectives

Greg Whitcomb DC

Assistant Professor

Department of Neurosurgery

Medical College of Wisconsin


Disclosure

• Nothing to disclose


PERIPARTUM BACK & PELVIC PAIN: OVERVIEW & UPDATE

Incidence and Who is Affected

General Review of Regional Anatomy

Classification of Antepartum Axial and Pelvic Pain

The Anthropology of Bipedal Pregnancy

Biomechanics – What is Stability?

Form & Force Closure & The Role of Neuromotor Strategies

Evidence for Pre and Post-Partum Care

Downstream Affects


Pelvic Girdle & Low Back Pain + 45% During Pregnancy

25% Postpartum

‘Serious’ Antepartum Pain the Number Drops to 25%

Majority of Women Recover Within 3 months Postpartum

5–7% Report Chronic Postpartum LB

PREVALENCE

Wu W et al European Spine Journal 13(7); 575, 2004)


Vleeming A et al Churchill Livingstone – Elsevier Publishers 2007

RISK & NON-RISK FACTORS

Previous LBP or Prior [Regional] Trauma – Moderate Evidence

Multigravida & High Work – Modest Evidence

Time Interval – No Evidence

BCPs – No Evidence

Age – No Evidence

Height & Weight – No Evidence

Current Fitness – Not Studied


1 Spinal Canal

2 Posterior VB

3 Spinous Process

4 Inferior AP

5 Lamina

6 Mamillary Process

7 TVP

8 Superior AP

9 Facet Surface

Facets Guide Anterior Column & Resist Sheer/Rotational Forces


Lumbar Ligaments and Disc Also Resist Sheer Forces

Compound Restraint Mechanisms


A Word About SI Joints ….

SI Motion is Present but MM

SIJ Mobility + 30-40% > Women

Muscle Force Decreases SI Motion

SI Movement Smaller Loaded and Greater Unloaded

Asymmetric Motion with BL Pain

Movement, Stability & Lumbopelvic Pain: Integration of Research & Therapy

Vleeming A et al

Churchill Livingstone – Elsevier Publishers 2007


Stability is Controlled in Multiple Planes

The Low Back, Pelvis Are Dependent on

Muscular Stability for Controlled

Motion & Load Distribution


aSexual Dimorphism of the L3 Vertebral Body

Fetal Load & The Evolution of Lumbar Lordosis in Bipedal Hominins

Whitcome K et al Nature 450, 1075-1078 (13 December 2007)


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Center of Mass Fluctuates Substantially

Whitcome K et al Nature 450, 1075-1078 (13 December 2007)

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a Cost To Stabilize COM

Nearly 60% Increase in Lordosis & Resultant Sheer on Lumbar Facet Joints


Love T W

Degenerative Spondylolisthesis: Developmental or Acquired?.

JBJS Br;82(2):307-8; 2000

Degenerative Spondylolisthesis 4 X More Common in Women

Increased Facet Angle Due to Arthritic Remodeling Not the Primary Cause DS

More Likely Related to Decreased Soft-tissue Resilience With Subsequent Failure of the Facets to Restrain Anterolisthesis


Female Gender & Higher Facet Joint Angle Consistently Associated

With an Increased Risk of DS Across Multiple Studies

Risk Factors for Degenerative Spondylolisthesis: A Systematic Review

Devine A et alEvidence-Based Spine Journal 3(2):25-34; 2012


Form Closure

Force Closure


Global Muscular Stabilization of the Spine & Pelvis

Van Windergarden JP et al

European Spine Journal 2;140-44, 1993


Moving Differently in Pain: A New Theory to Explain the Adaptation to Pain

Hodges P, Tucker K - PAIN 152:3 Suppl;S90-8, 2011


Findings Show Altered Motor Control Strategies & Respiratory Fx in Subjects With SIJ Pain

Suggest Compensatory Neuromuscular Strategy for Pelvic Force Closure

Where Stability Has Been Compromised by Injury

Respiratory Patterns Recorded With Spirometry With Minute Ventilation

Diaphragmatic Excursion and Pelvic Floor Descent Measured With Ultrasonography

Altered Motor Control Strategies in Subjects With SI Joint Pain During the Active Straight-Leg-Raise Test

O’Sullivan P et al

SPINE Vol 27(1):E1-E8; 2002


52% Reported a Combination of LBP and/or PGP With Pelvic Floor Dysfunction

Of These 82% Developed Initial Symptoms As Either LBP and/or Pelvic Girdle Pain

Relations Between PRLBP Pelvic Floor Activity & Dysfunction

Pool-Goudzwaard et al

Int Urogyn Journal Pelvic Floor Dysfunction 2005;16(6):468-74


Validity of the Active SLR For Measuring Disease Severity in Patients

With Posterior Pelvic Pain After Pregnancy

Mens A et alSPINE 27(2):196-200; 2002


Remember, Balance is the Key to Life !!


European Guidelines For the Diagnosis & Treatment of Pelvic Girdle Pain

Eur Spine J Jun;17(6):820-1; 2008

Manipulation & Mobilization – No Evidence

Bracing – Limited to No Evidence

Activity Modification – Not Studied


Pickar J - The Spine Journal 2002

Haavik-Taylor H – Clinical Neurophysiology 2007

Dishman D – The Spine Journal 2003

Beyond Joints– Neurophysiological Effects of Manual Treatment

Stimulate Proprio/Mechanoreceptive Afferents

Modulation of Central Sensitization – Nociceptive Inhibition

Modulation of [Peripheral] Alpha Motoneuronal Activity

Excitation of Central Corticospinal Activity


2 Year F/U of a RCT of Spinal Manipulation

and Two Types of Exercise for Patients With Chronic Back Pain

Evans R, Bronfort G, Nelson B et al

SPINE 27 (21);2383-2389, 2002

BETTER WHEN COMBINED WITH EXERCISE


Postural Control Involves Rapid Reflex Actions of Central Stabilizers

Stimuli [Stiffness, Weakness, Pain & Avoidance] Alter Posture & Movement

Adaptive Strategies Emerge to Maintain Upright Stance & Ambulation

Sustained Neuromotor Alterations Result & the NMS System Habituates

MT Associated with Decreased Pain & Stiffness

MT Research Suggests a Short-Term “Neuromotor Reset” Helpful to Rehab

Re-establishing Stable, Healthy Movement is Linked to Recovery !!

IN SUMMARY


Treatment Effect Versus Rehab Effect


WHAT CAN IT HURT ?

OH, MY ACHING BUTT !


Stuge B et al

SPINE Vol 29(4):351-59; 2004

The Efficacy of a Treatment Program Focusing On Specific

Stabilizing Exercises For [PGP] After Pregnancy: A RCT

81 Women With PP PGP - Two Treatment Groups 20 weeks

Group Specific Stabilizing Exercises

Group Individualized PT Without Stabilizing Exercises.

Blinded Assessments at Baseline, Post-Intervention and 1 YR PP F/U

Main Outcome Measures Included Pain (VAS) Functional Status (ODI) & QOL SF-36


Disability Reduced >50% for the Exercise Group

Individualized Specific Exercises Better Than Usual Care

Stuge B et al

SPINE Vol 29(4):351-59; 2004

STABILIZATION TRAINING


Thank You Dr. Jones And MCW OB/GYN !

[email protected]

4-Whitcomb Greg-The Biomechanics of Pregnancy · 2015-04-13 · Greg L. Whitcomb, BS, DC The...

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