BIOMECHANICAL CHANGES IN THE LOWER BACK DURING THE … · Pregnancy is a period of various...

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INTERDISCIPLINARY JOURNAL OF CONTEMPORARY RESEARCH IN BUSINESS

COPY RIGHT © 2012 Institute of Interdisciplinary Business Research

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BIOMECHANICAL CHANGES IN THE LOWER BACK DURING THE

THIRD TRIMESTER OF PREGNANCY DR.MARIA AHMAD

1,DR.MUHAMMAD SALMAN BASHIR

2.DR.SYED IMTIAZ

HUSSAIN SHAH3,DR IMRAN GHAFOOR

4.

SCHOOL OF ALLIED HEALTH SCIENCES CHILDREN HOSPITAL LAHORE,RIPHAH INTERNATIONAL UNIVERSITY

LAHORE,RIPHAH INTERNATIONAL UNIVERSITY LAHORE,KING EDWARD MEDICAL UNIVERSITY LAHORE.

ABSTRACT

Pregnancy is a period of various physiological and ph ysical adaptations. During

this process a lot of biomechanical changes are confronted by the female body.

These biomechanical changes, although temporary, lead to debilitating back pain

especially in the lumbar area. They may include sway back posture, leg length

discrepancy, hormonal changes, stretched and weakened muscles and

compression of sciatic nerve. Objective: This study is aimed at determining the

biomechanical changes in the lower back of pregnant females which is their

cause of discomfort .Method: This observational study included 50 females in

their third trimester of pregnancy that completed a questionnaire regarding their

low back pain and i ts potentially influencing factors. The data was collected

from patients coming to the gynecology departm ent of Fatima Memorial

Hospital, Lahore. Results: Showed that out of 50 patients, leg length

discrepancy occurs in 24%, lumbar curve exaggeration in 58%, muscle girth

difference in 20%, and radiating sciatic like pain in 50% of pregnant females.

Previous history of back pain is also an evident factor in predisposition of low

back pain in pregnancy. Conclusion: Hence it is concluded that lower back pain

is common in pregnant women especially in their third trimester. Females with a

history of back pain are more likely to develop discomfort during pregnancy.

The timing of symptom onset in mid to late pregnancy may suggest that

biomechanical factors particularly postural imbalances play a larger role than

hormonal influences.

Keywords: BIOMECHANICAL CHANGES ; LOWER BACK ; THIRD

TRIMESTER OF PREGNANCY

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INTRODUCTION:

During pregnancy, women gain 25 to 35 pounds, on average, and undergo

multiple hormonal changes and biomechanical alterations which impact the

musculoskeletal system, result ing in back pain. Exagge rated lordosis of the

lower back causes the weight of the growing baby to be carried by the pubic

bones at the front of the pelvis and by the abdominal muscles exerting more

pressure on the pelvic floor muscles and the pelvic ligaments. A significant

increase in the anterior tilt of the pelvis occurs and stance is widened to

maintain trunk movement.

Hormonal fluctuations are bound to cause some discomfort and as

pregnancy progresses, the concentration of relaxin hormone rises causing laxity

of the joints and ligaments so as to accommodate the growing uterus and provide

enough room for the baby to be delivered. Joint laxity in the longitudinal

ligaments of the lumbar spine creates more instabili ty and can predispose to

muscle strain. Relaxin also causes th e abdominal muscles to expand sideways

leading to diastasis recti. Multiple births and repeated pregnancies aggravate the

condition.

Sacro Il iac joint dysfunction may also be caused by hormonal changes.

There is widening and increased mobility of the sa croiliac joints and pubic

symphysis in preparation for the fetus ' passage through the birth canal causing

altered joint mechanics and pain. Some pregnant women may experience

sciatica, a sharp pain down the back of the thigh that is caused by one of the

nerves of the thigh being squashed as it travels down the leg. Sciatica and

pregnancy go together for many women simply because the additional stress of

carrying the baby is what pushes the body beyond its ability to adapt. Those

underlying disc injuries are exacerbated by the weight and posture of pregnancy,

resulting in sciatic nerve disturbance and sciatica pain, either in the back, the

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buttocks or the legs . In susceptible women, pregnancy may be a factor for the

development of degenerative spondylolisthes is.

METHODOLOGY:

Study design:

Observational study.

Sample design:

Convenience method.

Settings:

The study will be conducted at the Department of Gynaecology, Lahore General

Hospital and the Department of Gynaecology, Fatima Memorial Hospital, Lahore .

Duration of study:

3 months after the approval of synopsis.

Study group:

Pregnant women in their 3rd

t rimester.

Sample size:

This was a time based study of 3 months. 50 patients were included in that period

of t ime.

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Sampling Technique:

Convenient and Purposive Non Random Sampling technique w as used.

Sample selection criteria:

Inclusion criteria:

1. Prima gravida

2. Pregnancy in its 3rd

t rimester

3. Patients up to 35 years of age

Exclusion criteria :

1. C-section

2. Gestational diabetes

3. Patients undergoing pre eclempsia

4. Multiple pregnancy

Methodology:

The assessment is done according to the postural -structural-biomechanical

model (PSB):

Static postural examination:

The shape of the back is observed, whether there are anyincreases in spinal

curves such as scoliosis, kyphosis or lordosis.

Pelvic angleis measured in the coronal plane, pelvic nutation and

counternutation angles, the relative position of the sacrum to the ilia and leg

length differences.

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Dynamic assessment:

It is done in standing in which the spine is examined in all plane of motion.

Regional and segmental movement losses and stiffness is observed and often

used to determine the severity of the spinal condition and is also used to explain

the cause of the condition.

Palpatory examination:

It is performed during standing or lying on the treatment table. Information is

gathered about abnormal t issue textures, unusual muscle stiffness or abnormal

relationships between body masses, muscle bulks or position of vertebral

landmark

Data Collection Tools/Instruments

Structure questioner guide was used to collect data. From these questionnaire

data was collected about patients, gender, age and medical history of disease

STATISTICAL ANALYSIS:

Using SPSS v.17 the data was managed and anal yzed. The continuous variables

were expressed as mean ±S.D. whereas categorical variables were expressed in

the form of frequency table and percentages. Appropriate graphs are used to

display the data.

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RESULTS: This observational study was based on 3 m onths’ time period and 50

patients were studied. A Performa was used for each patient, which was filled

out based on history and examination. All of the patients were pregnant females under the age of 35,

primagravidas and in their third trimesters as cons idered in the inclusion

cri teria. Their body has undergone numerous changes to accommodate the

growing baby inside. 44% of these women were 40 -45 kg before getting

pregnant. 54% of them were 50 -55 kg and only 2% were 60-65kg. During their

third trimester the weight of 44% women has increased to 60 -65 kg whereas 64%

of them were in the range of 70-75kg.

This increase in weight was confronted by the body by adaptation of some

biomechanical changes which helped them in carrying the increasing load of the

baby.

When asked, al l of them responded with the same answer of debilitating

back pain and spinal stiffness. Out of 50 patients 31 had the history of previous

back pain.

On examination of leg length 24% of the pregnant women presented with

leg length discrepancy which in other words is shortening of one leg causing

postural and gait deformities. 20% of the pregnant women showed girth

difference in arm, thigh and leg muscles.

56% of them had positive radiating, sciatic -like pain in their back and

legs. Out of these 22% women had pain radiating up to knee, 24% had pain up to

foot and 4% had pain radiating in both legs.

On postural examination, 58% of them showed exaggerated lumbar curve

which was caused by stretched abdominal muscles and weakened spin al muscles.

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DISCUSSION:

The purpose of my study was to determine the biomechanical changes

occurring in the lower back during the third trimester of pregnancy. These

changes although help females to carry their growing fetus, they have an

extremely painful and discomforting effect and lead to functional disability in

women at this period of time.

The factors responsible for back pain are postural changes that are leg

length discrepancy, girth difference in the muscles of arms, thighs and legs,

lumbar curve exaggeration and radiating pain in the lower limbs caused by

compression of sciatic nerve.

This study proves that the most influencing features among these are the

previous history of back pain. The second most promising biomechanical change

is the compression of sciatic nerve leading to radiating pain followed by leg

length discrepancy and girth differences.

These changes and the weakening and stretching of spinal muscles form a

vicious circle and continue to debil itate the body image of pregnant fem ale and

cause severe low back pain.

Many similar studies have been carried out with respect to this problem. I

suggest that research should be done and implemented in fields of pregnancy

counseling and training of postural awareness and control with the he lp of

proprioceptive and therapeutic techniques so as to strengthen the pregnant body

image and avoid weakening of related musculature.

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CONCLUSIONS:

Lower back pain is common in pregnant women especially in their third trimester. Females with a history of back pain are more likely to develop discomfort during

pregnancy.

The timing of symptom onset in mid to late pregnancy may suggest that

biomechanical factors particularly postural imbalances play a larger role than

hormonal influences.

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REFERENCES:

Bastiaenen, C.H.G., Hendriks, E.J .M., Pool -Goudzwaard, A.L., Bernards,

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Bullock, JE., Jull , GA., and Bullock, MI. (1987) The Relationship of Low Back

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Gilleard, W., Crosbie, J . , and Smith, R.(2002) Effect of pregnancy on trunk

range of motion when sit t ing and standing . Acta Obstet Gynecol Scand ; 81 :1011

Ireland, ML. and Ott , SM. Kentucky Sports Medicine , Lexington 40517, USA.

Jensen, R.K., Doucet, S., and T. Treit (1995) Centre for research in human

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Karzel, RP., and Freedman, MJ. (1991) Orthopedic injuries in pregnancy. In:

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Kausar S., Tajammul, A., Sheikh, S., Iqbal, S., and Anwar, S., (2007)

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Pennick, V. and Young, G.(2008) Interventions for preventing and treating

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Wang, et al (2004) Obstetr ics & Gynecology: - Volume 104 - Issue 1 - pp 65-70

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PERFORMA FOR DATA COLLECTION

Study serial no. Date of assessment:

Name of patient: Age:

Address: Contact no.

Socioeconomic status: Upper Middle Lower

Age at marriage:

Parity status: Primagravida Multigravida

Any previous history of back pain: Yes No

Trimester of pregnancy: 1st 2

nd 3

rd

Weight before pregnancy: 40-45kg 50-55kg 60-65kg

Weight during pregnancy: 50-55kg 60-65kg 70-75kg

Complain of spinal stiffness: Yes No

Leg length discrepancy: Yes No

Length: Right Left

Girth measurement: Right Left

Arm:

Thigh:

Leg:

Observation of lumbar curve: Normal Exaggerated

Radiating pain: Yes No

Please specify if yes:

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TABLES:

Weight before and during pregnancy:

History of back pain:

FEATURES

RANGE

FREQUENCY

PERCENTAGE

WEIGHT BEFORE

PREGNANCY

40-45kg

50-55kg

60-65kg

22

27

1

44%

54%

2%

WEIGHT DURING

PREGNANCY

50-55kg

60-65kg

70-75kg

0

18

32

0%

36%

64%

FACTOR FREQUENCY PERCENTAGE

HISTORY OF BACK

PAIN

YES

NO

31

19

62%

38%

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Percentage of normal and exaggerated lumbar curve:

Percentages of biomechanical changes responsible for back pain in pregnancy.

Percentage of radiating pain and its distribution.

LUMBAR CURVE VALUE FREQUENCY

NORMAL 21 42%

EXAGGERATED 29 58%

FACTORS CAUSING

BACK PAIN

VALUES

PERCENTAGE

LEG LENGTH

DISCRIPANCY

12

24%

GIRTH DIFFERENCE

10

20%

RADIATING PAIN

28

56%

RADIATING PAIN

FREQUENCY

PERCENTAGE

NO PAIN

25

50%

PAIN UP TO KNEE

11

22%

PAIN UP TO FOOT

12

24%

PAIN IN BOTH LEGS

2

4%

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Frequency of biomechanical changes in pregnancy.

Normal and exaggerated lumbar curve:

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