Disturbed body perception, reduced sleep, and kinesiophobia in subjects with pregnancy-related persistent lumbopelvic pain and moderate levels of disability: An exploratory study

Educating women to prevent and treat low back and pelvic girdle pain during and after pregnancy: a systematized narrative review

PURPOSE

This review evaluated the effectiveness of patient education and information on low back pain (LBP) and pelvic girdle pain (PGP) in pregnant and postpartum women and evaluated their alignment with modern pain education principles rooted in the biopsychosocial model.

METHOD

A systematized narrative review was performed, including a systematic search of three databases and reference screening from relevant systematic reviews. The methodological quality of the included randomized controlled trials (RCT) was evaluated using the PEDro scale.

RESULTS

Eighteen studies, including nine RCTs with PEDro scores ranging from to 2-8, indicated that patient education during pregnancy can help reduce pain and related disability. Most studies did not differentiate between LBP and PGP, which limits the specificity and targeted approach of educational interventions. Education alone is less effective without accompanying active treatment. Current programs primarily emphasize biomechanics, covering anatomy and physical changes, but often neglect lifestyle factors, such as stress and sleep.

CONCLUSION

Although patient education is important for managing pregnancy-related LBP and PGP, its effectiveness may be improved by tailoring programs to specific pain conditions and integrating a biopsychosocial perspective on pain.

The Fremantle Back Awareness Questionnaire: Cross-cultural adaptation, validity and reliability of the Polish version

BACKGROUND

Body image disturbance is observed in individuals with chronic low back pain (CLBP) and is a potential treatment target. The Fremantle Back Awareness Questionnaire (FreBAQ) is designed to identify disrupted body image specific to the low back. This study aimed to develop and assess the measurement properties of a Polish language version of this questionnaire (FreBAQ-PL).

METHODS

Following the translation process, cognitive interviews were carried out as a qualitative assessment of content validity. Subsequently a quantitative assessment of content validity was undertaken among in a study sample with CLBP and experts. Measurement properties were assessed in 114 participants with CLBP and 53 pain-free participants. The CLBP sample repeated the FreBAQ-PL assessment within 14-days. The measurement properties assessed in this study were content validity, internal consistency, frequency of responses, known-groups validity, convergent validity and test-retest reliability.

RESULTS

Content validity was supported, affirming relevance and comprehensiveness. Known-groups validity was confirmed by significant differences in FreBAQ-PL scores between participants with CLBP and pain-free participants (p < 0.05). Convergent validity was established through moderate associations between FreBAQ-PL scores and pain variables (intensity and duration) (ρ's = 0.24-0.27, p's < 0.01), disability (ρ = 0.34, p < 0.01), kinesiophobia (ρ = 0.37, p < 0.01), depression (ρ = 0.30, p < 0.01) and anxiety (ρ = 0.24, p < 0.01). The scale was internally consistent (Cronbach's alpha 0.81). Test-retest reliability was good (ICC 0.90).

CONCLUSIONS

The FreBAQ-PL is a reliable, internally consistent, and valid measure that can be used in clinical and research settings to assess the presence of body image disturbance in Polish-speaking individuals with CLBP.

Impact of exercise on musculoskeletal pain and disability in the postpartum period: a systematic review and meta-analysis

OBJECTIVE

To examine the impact of exercise on musculoskeletal pain (low back pain (LBP), pelvic girdle pain (PGP), lumbopelvic pain (LBPP) and bodily pain) and kinesiophobia during the postpartum period.

DESIGN

Systematic review with random effects meta-analysis.

STUDY ELIGIBILITY CRITERIA

Online databases were searched from database inception to 12 January 2024. Studies of all designs (except case studies) of any publication date or language were included if they contained information on the population (women and people in the first year postpartum), intervention (subjective or objective measures of frequency, intensity, duration, volume or type of exercise, alone ('exercise-only') or in combination with other interventions (eg, electrotherapy, infrared irradiation, ultrasound; 'exercise+cointervention')), comparator (no exercise or different exercise measures) and outcome (symptom severity of LBP/PGP/LBPP, related disability, bodily pain and kinesiophobia).

RESULTS

37 studies (N=3769 participants) from 15 countries were included. Moderate certainty evidence showed that exercise-only interventions, including various strengthening exercises targeting the trunk muscles, were associated with a greater reduction in LBPP symptom severity (4 randomised controlled trials (RCTs), n=210; mean difference -2.21 points (on a 0-10 Visual Analogue Scale) 95% CI -3.33 to -1.08) and related disability (6 RCTs, n=296; standardised mean difference -1.17, 95% CI -1.92 to -0.43; large effect size) as compared with no exercise. Similar results were found for bodily pain (2 RCTs, n=318). Evidence was limited and inconclusive regarding the impact of exercise interventions on kinesiophobia.

CONCLUSION

Postnatal exercises, including a variety of muscular strengthening exercises targeting the trunk muscles, decrease the symptom severity of LBPP and related disability.

Self-reported questionnaires assessing body perception disturbances in adults with chronic non-cancer pain: a scoping review

Introduction

Body perception disturbances (BPD) are well documented in certain chronic pain populations [e.g., complex regional pain syndrome (CRPS)], while being far less studied in chronic pain as a general condition. The aims of this scoping review are to identify the self-reported questionnaires used to assess BPD in individuals with chronic non-cancer pain and to refine the definition of the BPD construct as used in these questionnaires.

Methods

A search strategy focusing on the concepts of "chronic pain", "body perception" and "questionnaire" was used across four databases. Each record was screened for eligibility by two independent reviewers, and data extraction was performed by one reviewer and validated by a second reviewer.

Results

Eighty-seven studies were included, comprising 18 different questionnaires-either directly related to BPD or containing relevant items. The three most commonly used questionnaires were the Bath Body Perception Disturbance Scale, the Fremantle Back Awareness Questionnaire, and the Neurobehavioral Questionnaire. Appraisal of the construct derived from the questionnaire items identified five main facets: size, shape, cognitive neglect-like symptoms, proprioceptive awareness, and agency, along with 11 other less frequently addressed facets. The most represented clinical populations were CRPS (40 studies) and chronic low-back pain (20 studies).

Discussion

A variety of self-reported questionnaires are available to assess BPD, but most are diagnosis- or body-region specific. To better assess BPD in individuals with chronic non-cancer pain, a consensus on the general definition and the key facets of the construct is needed.

The prevalence of postpartum depression among women with physical disabilities: a systematic review and meta-analysis

PURPOSE

Pregnant and postpartum mothers with physical disabilities face discrimination in healthcare settings and high rates of maternal and obstetric complications, as well as having higher rates of lifetime depression prior to pregnancy, potentially increasing their likelihood of experiencing postpartum depression (PPD). Some studies have found higher rates of PPD in mothers with physical disabilities than in mothers without physical disabilities, with more disabling symptoms associated with worse PPD systems; however, the literature is sparse and heterogenous. This systematic review and meta-analysis advanced this area of study by evaluating the strength of the association between PPD and physical disability.

METHODS

We searched PubMed and PsycInfo, with the primary inclusion criteria being that the studies had an established measure of depression in women during the postpartum period and either a cohort identified as having physical disability or an established measure of physical disability in a general population sample. We aggregated the prevalence of PPD in women with physical disabilities and tested the robustness of our findings to moderators, including region, sample population, and measure type.

RESULTS

Findings from our quantitative meta-analysis (n=14) demonstrated a strong (d=.76, p<.0001) association between PPD and physical disabilities, such that individuals with physical disabilities reported more depression symptoms than individuals without physical disabilities. Moderator analyses were null, revealing that the association between PPD and physical disabilities was robust to several variables. Qualitative results support our conclusion that individuals with physical disabilities are at increased risk of PPD symptoms.

CONCLUSION

Our findings of a strong association between physical disability and PPD support the need for more research. Additional studies would 1) augment a nuanced understanding of how best to conceptualize PPD in women with physical disabilities and 2) facilitate testing the robustness of the association between PPD and physical disabilities to additional important moderators.

Body awareness disturbances in patients with low back pain: a systematic review

BACKGROUND

The pain-neuroscience literature has recently emphasized body perception or awareness. Impaired body perception results have been reported in many different chronic pain problems. Studies have reported that individuals with low back pain (LBP) also have body perception disturbances related to the lumbar spine.

OBJECTIVES

This review aimed to determine the evidence that body awareness alterations in individuals with LBP.

DESIGN

Systematic review.

METHOD

Studies were searched in PubMed, Cochrane Library, and Pedro databases up to January 2021. Each database was searched independently, according to a specific iteration research string. The protocol record of the systematic review was entered into the PROSPERO system.

RESULTS

Nine studies were included in this research. We found evidence to support more perceptual impairments in patients with LBP than healthy counterparts. In addition, the results of the studies showed an association between disrupted body awareness and pain severity, pain catastrophizing, and disability.

CONCLUSIONS

Body perception disturbances in LBP seem to be a promising path that needs to be further explored, with the ultimate goal of developing treatment contents targeting body awareness as a more comprehensive and valid evaluation and therapeutic method.

TRIAL REGISTRATION

The registration number was CRD42021235934.

Body Image Measured via the Fremantle Awareness Questionnaire in Individuals With and Without Pain: A Systematic Review and Meta-Analysis

Research suggests that pain negatively affects body image, and body image may also influence reported pain levels. This review aims to summarize the literature on differences in body image distortion between individuals with pain compared to pain-free individuals. The review was conducted according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses 2020 statement and an a priori preregistered protocol. The literature was searched using 5 electronic databases. Studies assessing body image with the Fremantle Awareness Questionnaire (FAQ) in individuals with and without pain were eligible for inclusion. Screening and selection of eligible studies were performed by independent reviewers. Methodological quality was assessed with the Joanna Briggs Institute critical appraisal tool. Meta-analyses, meta-correlations, and metamean analyses were performed using random-effect models. The primary outcome was the FAQ score; secondary outcomes were reported pain variables. Data from individuals with pain (n = 2277) and without pain (n = 615) were summarized. Significant body image distortions were found in individuals with pain compared to individuals without pain. Compared to pain-free individuals, the pain group rated significantly higher in the FAQ when experiencing back pain (standardized mean differences=1.33, 95% confidence interval=.88-1.77) or other body parts (standardized mean differences=1.25, 95% confidence interval=.51-1.99). The results of meta-correlation analyses confirmed the positive relationship between body image distortion and pain intensity (r = .31), pain at rest (r = .31), or pain during movement (r = .36), but not for pain duration. A difference in mean FAQ results was observed between individuals with pain in different areas (knee and back). PERSPECTIVE: This review confirms differences in body image distortion between pain and pain-free individuals. Pain intensity was correlated with altered body perception, but not pain duration. A moderate correlation was observed between body image distortion and reported pain variables. Body image was more impaired by knee pain than back pain. REGISTERED PROTOCOL AT PROSPERO: CRD42022309937; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022309937.

Characteristics and effects on daily lives of pelvic girdle pain during early postpartum in Beijing women, China

Pelvic girdle pain (PGP) is a common problem during pregnancy and postpartum and negatively affects women's well-being. Yet it is not well known in China. This study assessed PGP's intensity, location, and quality and the status of daily activities on postpartum women with pain, and explored the relationship between pain and the prevalence of depressive symptoms. A cross-sectional study recruiting 1,038 eligible women at 6 weeks postpartum from the obstetric clinic of a hospital was conducted in Beijing, China. Data were collected using self-reported questionnaires, including Introductory information form, Body chart, Number Rating Scale, McGill Pain Questionnaire-2, Pelvic Girdle Questionnaire, and Edinburgh Postnatal Depression Scale. In this study, 32.2 percent women experienced pain. The mean (SD) pain intensity score was 3.07 ± 1.60. About 50.6 percent women experienced sacroiliac joint pain, and 25.5 percent women experienced pain in a combination of locations. About 73.1 percent women experienced aching pain, and 57.5 percent experienced more than one kind of pain quality. The mean total score, which assesses activity and symptom limitations, was 21.93 ± 17.35 (percent), of which a normal sex life (1.29 ± 0.94) was made more challenging due to pain. In mental health, the prevalence of depressive symptoms coincided with the prevalence of pain (p = 0.008). Postpartum PGP still needs to be taken seriously, and women with pain require further support. The above knowledge offers information to manage pain, daily lives and depressive symptoms, contributes to think about strategies to better promote postpartum women physical and mental health in the future.

Predictive Factors for Pregnancy-Related Persistent Pelvic Girdle Pain (PPGP): A Systematic Review

Background and Objectives: To identify the most frequently reported predictive factors for the persistency of pregnancy-related pelvic girdle pain (PPGP) at 3-6 months after childbirth in women with PPGP alone or PPGP in association with pregnancy-related lower back pain (PLBP). Methods: Eligibility criteria: Two authors independently selected studies excluding PPGP determined by a specific, traumatic, gynecological/urological cause or isolated PLBP and studies that did not include the presence/absence of PPGP as the the primary outcome. We, instead, included studies with an initial assessment in pregnancy (within 1 month of delivery) and with a follow-up of at least 3 months after delivery. Data sources: The research was performed using the databases of Medline, Cochrane, Pedro, Scopus, Web of Science and Cinahl from December 2018 to January 2022, following the indications of the PRISMA statement 2021 and the MOOSE checklist. It includes observational cohort studies in which data were often collected through prospective questionnaires (all in English). Study appraisal and risk of bias: Two independent authors performed evaluations of the risk of bias (ROB) using the quality in prognostic studies (QUIPS) tool. Synthesis of results: An in-depth qualitative analysis was conducted because, due to a high degree of heterogeneity in the data collection of the included studies and a lack of raw data suitable for quantitative analysis, it was not possible to carry out the originally planned meta-analyses for the subgroups. Results: The research process led to the inclusion of 10 articles which were evaluated using the QUIPS tool: 5 studies were evaluated as low ROB and 5 were evaluated as moderate ROB. High levels of pain in pregnancy, a large number of positive provocation tests, a history of lower back pain and lumbo-pelvic pain, high levels of disability in pregnancy, neurotic behavior and high levels of fear-avoidance belief were identified as strong predictors of long-term PPGP, while there was weak or contradictory evidence regarding predictions of emotional distress, catastrophizing and sleep disturbances. Discussion: The impossibility of carrying out the meta-analysis by subgroups suggests the need for further research with greater methodological rigor in the acquisition of measures based on an already existing PPGP core predictors/outcome sets.

The relationship of pain, disability, physical activity, and body awareness with kinesiophobia in pregnant women with low back pain

PURPOSE/AIM

To investigate the relationship of pain intensity, disability level, physical activity level, and body awareness with kinesiophobia in pregnant women with low back pain (LBP).

MATERIALS AND METHODS

This cross-sectional study was conducted in the obstetrics and gynaecologic clinic of a tertiary centre. Eighty-six pregnant women were included in the study. Pain intensity, disability level, physical activity, body awareness, and kinesiophobia were assessed with a Visual Analogue Scale, the Oswestry Disability Index (ODI), the International Physical Activity Questionnaire-Short Form (IPAQ-SF), the Body Awareness Questionnaire (BAQ), and the Tampa Scale for Kinesiophobia (TSK), respectively.

RESULTS

Kinesiophobia score was high in pregnant women with LBP (40.01 ± 9.02). In pregnant women with LBP, a weak positive correlation was found between kinesiophobia with mean intensity of LBP (r = 0.339, p = 0.001) and intensity of LBP in activity (r = 0.283, p = 0.008); a moderate positive correlation between kinesiophobia and disability score (r = 0.539, p = 0.001); and a weak negative correlation between kinesiophobia and physical activity level (r = -0.308, p = 0.004) and body awareness (r = -0.324, p = 0.002). There was no relationship between kinesiophobia and intensity of LBP at rest (r = 0.160, p = 0.142) and nocturnal LBP intensity (r = 0.176, p = 0.105).

CONCLUSIONS

LBP intensity, disability level, physical activity level, and body awareness were significantly correlated with kinesiophobia in pregnant women with LBP. Therefore, kinesiophobia may be addressed as an important issue in pregnancy education programs.

Inter- and Intra-Examiner Reliability Study of Two-Point Discrimination Test (TPD) and Two-Point Estimation Task (TPE) in the Sacral Area of Pain-Free Individuals

Tactile acuity is typically measured by a two-point discrimination test (TPD) and a two-point estimation task (TPE). In the back area, they are only conducted in the lumbar and cervical regions of the spine. Considering that such measurements have not been conducted in the sacral regions, the purpose of this study was to assess the inter- and intra-examiner reliability of the TPD and TPE at the level of the S3 segment. The study included 30 pain-free subjects aged 20-30 years. Tests were performed with a pair of stainless hardened digital calipers. The TPD was measured in two locations: 5 and 15 cm from the midline; for TPE both, points were located inside the measured area. Session 1 involved assessments by two examiners in 10-min intervals. Session 2 was measured by one examiner, at analogous intervals between tests. The TPD inter-rater reliability was excellent for mean measurements (ICC3.2: 0.76-0.8; ICC3.3: 0.8-0.92); the intra-rater reliability was excellent for mean measurements (ICC2.2: 0.79-0.85; ICC2.3: 0.82-0.86). The TPE inter-rater reliability was good to excellent for mean measurements (ICC3.2: 0.65-0.92; ICC3.3: 0.73-0.94); the intra-rater reliability for all studies (ICC2.1, ICC2.2, ICC2.3) was excellent (0.85-0.89). Two measurements are sufficient to achieve good reliability (ICC ≥ 0.75), regardless of the assessed body side.

Telerehabilitation for persistent Pelvic Girdle Pain within a biopsychosocial framework - A case report

BACKGROUND

Persistent pregnancy-related pelvic girdle pain (PGP) and the resulting consequences may considerably influence a woman's quality of life. The complexity of this condition requires a whole-person centered approach. In response to COVID-19 outbreak, telerehabilitation has emerged as a promising alternative to traditional in-person visits.

PURPOSE

The aim of this report was to present the potential of telerehabilitation for persistent postpartum PGP within the biopsychosocial framework.

CASE DESCRIPTION

A 26-year-old female presented with persistent pregnancy-related PGP of 8 months duration after her first vaginal delivery. The video-consults were performed using telerehabilitation platform. The patient received six telerehabilitation consults of 45 min duration over five weeks. Assessment of physical and psychosocial factors, cognitively focused strategies including pain neurophysiology education, sensory-motor remapping exercises, and graded increase of activity were administered. Rehabilitation was divided into the following phases: assessment, desensitization, graded exposure, and supported independence.

OUTCOMES

The Pelvic Girdle Questionnaire (PGQ) score was significantly reduced from 72.2 during the assessment to 15.3 at discharge. This change was significantly more substantial than the minimal clinically important change estimated for the PGQ.

CONCLUSION

Physiotherapists can utilize telerehabilitation to assist them with enacting appropriate care measures for persistent PGP within a biopsychosocial framework.

Neglect-like symptoms and their relationships with other clinical features in people with hand osteoarthritis: An exploratory study

BACKGROUND

Symptomatic hand osteoarthritis (OA) is a debilitating condition. Body schema impairments such as neglect-like symptoms have been previously reported in people with symptomatic hand OA, however, little is known about their clinical importance, or relationships with other clinical features.

OBJECTIVES

The aim of this cross-sectional study was to assess the prevalence of neglect-like symptoms in painful hand OA and their association with measures of depression, pain catastrophising, sleep quality, function, pain interference and pain duration whilst controlling for important covariates.

DESIGN

Secondary analysis of cross-sectional study.

METHODS

Logistic regression with age, sex, and worst pain intensity as covariates were utilised to assess differences between participants with and without neglect-like symptoms.

RESULTS

A total of 121 participants were recruited. Sixty-one percent of participants presented with neglect-like symptoms. Participants with longer pain duration had greater odds of presenting with neglect-like symptoms (OR: 1.10 95%CI: 1.01 to 1.19; p = 0.012). No difference was observed for depression, pain catastrophising, sleep quality, function, or pain interference.

CONCLUSIONS

A large proportion of participants with symptomatic hand OA reported neglect-like symptoms, the presence of which was associated with longer pain duration.

Lifestyle and Chronic Pain in the Pelvis: State of the Art and Future Directions

During their lifespan, many women are exposed to pain in the pelvis in relation to menstruation and pregnancy. Such pelvic pain is often considered normal and inherently linked to being a woman, which in turn leads to insufficiently offered treatment for treatable aspects related to their pain experience. Nonetheless, severe dysmenorrhea (pain during menstruation) as seen in endometriosis and pregnancy-related pelvic girdle pain, have a high impact on daily activities, school attendance and work ability. In the context of any type of chronic pain, accumulating evidence shows that an unhealthy lifestyle is associated with pain development and pain severity. Furthermore, unhealthy lifestyle habits are a suggested perpetuating factor of chronic pain. This is of specific relevance during lifespan, since a low physical activity level, poor sleep, or periods of (di)stress are all common in challenging periods of women’s lives (e.g., during menstruation, during pregnancy, in the postpartum period). This state-of-the-art paper aims to review the role of lifestyle factors on pain in the pelvis, and the added value of a lifestyle intervention on pain in women with pelvic pain. Based on the current evidence, the benefits of physical activity and exercise for women with pain in the pelvis are supported to some extent. The available evidence on lifestyle factors such as sleep, (di)stress, diet, and tobacco/alcohol use is, however, inconclusive. Very few studies are available, and the studies which are available are of general low quality. Since the role of lifestyle on the development and maintenance of pain in the pelvis, and the value of lifestyle interventions for women with pain in the pelvis are currently poorly studied, a research agenda is presented. There are a number of rationales to study the effect of promoting a healthy lifestyle (early) in a woman’s life with regard to the prevention and management of pain in the pelvis. Indeed, lifestyle interventions might have, amongst others, anti-inflammatory, stress-reducing and/or sleep-improving effects, which might positively affect the experience of pain. Research to disentangle the relationship between lifestyle factors, such as physical activity level, sleep, diet, smoking, and psychological distress, and the experience of pain in the pelvis is, therefore, needed. Studies which address the development of management strategies for adapting lifestyles that are specifically tailored to women with pain in the pelvis, and as such take hormonal status, life events and context, into account, are required. Towards clinicians, we suggest making use of the window of opportunity to prevent a potential transition from localized or periodic pain in the pelvis (e.g., dysmenorrhea or pain during pregnancy and after delivery) towards persistent chronic pain, by promoting a healthy lifestyle and applying appropriate pain management.

Association between sleep disturbance and low back and pelvic pain in 4-month postpartum women: A cross-sectional study

PURPOSE

Persistent low back and pelvic pain (LBPP) is a postpartum-specific health problem. Sleep disturbances' association with persistent LBPP is not yet clear. We aimed to examine the cross-sectional association between sleep disturbance and persistent LBPP at 4 months postpartum.

METHODS

We enrolled 120 women with LBPP during pregnancy (mean age, 31.8; standard deviation, 4.9 years). The primary outcome was persistent LBPP. We assessed LBPP severity at 4 months postpartum using the Numerical Rating Scale (NRS), where women with an NRS score of ≥ 4 at 4 months postpartum were allocated to the persistent LBPP group. We assessed sleep disturbance at 4 months postpartum using the Japanese version of the Pittsburgh Sleep Quality Index with a total score of ≥ 6 indicating sleep disturbance. Moreover, we performed univariate and multiple logistic regression analyses to examine the cross-sectional association of sleep disturbance with persistent LBPP. The relevant confounding variables were age, body mass index, parity, and history of LBPP before pregnancy.

RESULTS

Among the 120 women, 45 women had persistent LBPP (37.5%) with 32 (71.1%) of them reporting sleep disturbance. There was a significant association of sleep disturbance with persistent LBPP (odds ratio [OR], 2.81; 95% confidence interval [95% CI], 1.28-6.19), which remained after adjustments for confounding variables (OR, 2.98; 95% CI, 1.31-6.75).

CONCLUSION

Our findings indicate that sleep disturbance is associated with persistent LBPP at 4 months postpartum; therefore, it should be taken into consideration in postpartum women with persistent LBPP.

Body perception disturbances in women with pregnancy-related lumbopelvic pain and their role in the persistence of pain postpartum

Background

Lumbopelvic pain (LPP) is common during pregnancy and can have long-lasting negative consequences in terms of disability and reduced quality of life. Therefore, it is crucial to identify women at risk of having pregnancy-related LPP after childbirth. This study aimed to investigate the association between body perception, pain intensity, and disability in women with pregnancy-related LPP during late pregnancy and postpartum, and to study whether a disturbed body perception during late pregnancy predicted having postpartum LPP.

Methods

A prospective cohort study in 130 primiparous women (median age = 30 years) was performed. Pain intensity, disability, and lumbopelvic body perception during the last month of pregnancy and 6 weeks postpartum were assessed with the Numerical Pain Rating Scale (NPRS), Oswestry Disability Index, and Fremantle Back Awareness Questionnaire, respectively. Having pregnancy-related LPP was defined as an NPRS score ≥ 1/10. At both timepoints, women were categorized into three groups; pain-free, LPP with low disability, and LPP with high disability (based on Oswestry Disability Index scores). At each timepoint, body perception was compared between groups, and correlations between body perception, pain intensity, and disability were evaluated in women with LPP by using non-parametric tests. Logistic regression analysis was used to determine whether body perception during the last month of pregnancy predicted the presence of LPP 6 weeks postpartum.

Results

Women with LPP at the end of pregnancy, and 6 weeks postpartum reported a more disturbed body perception compared to pain-free women (p ≤ 0.005). Greater body perception disturbance correlated with higher pain intensity (σ = 0.266, p = 0.008) and disability (σ = 0.472, p < 0.001) during late pregnancy, and with pain intensity 6 weeks postpartum (σ = 0.403, p = 0.015). A disturbed body perception during late pregnancy nearly significantly predicted having postpartum LPP (Odds Ratio = 1.231, p = 0.052).

Conclusions

Body perception disturbance was greater in women experiencing LPP during late pregnancy and postpartum compared to pain-free women, and correlated with pain intensity and disability. Though non-significant (p = 0.052), the results of the regression analysis suggest that greater body perception disturbance during late pregnancy might predict having LPP postpartum. However, future studies should follow up on this.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12884-021-03704-w.

A critical review of the biopsychosocial model of low back pain care: time for a new approach?

PURPOSE

Low back pain (LBP) is the leading cause of disability worldwide. Clinical research advocates using the biopsychosocial model (BPS) to manage LBP, however there is still no clear consensus regarding the meaning of this model in physiotherapy and how best to apply it. The aim of this study was to investigate how physiotherapy LBP literature enacts the BPS model.

MATERIAL AND METHODS

We conducted a critical review using discourse analysis of 66 articles retrieved from the PubMed and Web of Science databases.

RESULTS

Analysis suggest that many texts conflated the BPS with the biomedical model [Discourse 1: Conflating the BPS with the biomedical model]. Psychological aspects were almost exclusively conceptualised as cognitive and behavioural [Discourse 2: Cognition, behaviour, yellow flags and rapport]. Social context was rarely mentioned [Discourse 3: Brief and occasional social underpinnings]; and other broader aspects of care such as culture and power dynamics received little attention within the texts [Discourse 4: Expanded aspects of care].

CONCLUSION

Results imply that multiple important factors such as interpersonal or institutional power relations, cultural considerations, ethical, and social aspects of health may not be incorporated into physiotherapy research and practice when working with people with LBP.IMPLICATIONS FOR REHABILITATIONWhen using the biopsychosocial model with patients with low back pain, researchers narrowly focus on biological and cognitive behavioural aspects of the model.Social and broader aspects such as cultural, interpersonal and institutional power dynamics, appear to be neglected by researchers when taking a biopsychosocial approach to the care of patients with low back pain.The biopsychosocial model may be inadequate to address complexities of people with low back pain, and a reworking of the model may be necessary.There is a lack of research conceptualising how physiotherapy applies the biopsychosocial model in research and practice.

The Pelvic Girdle Pain deadlock: 2. Topics that, so far, have remained out of focus

INTRODUCTION

In our preceding paper, we concluded that Pelvic Girdle Pain (PGP) should be taken seriously. Still, we do not know its causes. Literature reviews on treatment fail to reveal a consistent pattern, and there are patients who do not respond well to treatment. We designated the lack of progress in research and in the clinic as 'deadlock', and proposed a 'deconstruction' of PGP, that is to say, taking PGP apart into its relevant dimensions.

PURPOSE

We examine the proposition that PGP may emerge as local inflammation. Inflammation would be a new dimension to be taken into account, between biomechanics and psychology. To explore the consequences of this idea, we present four different topics that, so far, have remained out of focus. One: The importance of microtrauma. Two: Ways to counteract chronification. Three: The importance of sickness behaviour when systemic inflammation turns into neuroinflammation of the brain. And Four: The mainly emotional and cognitive nature of chronic pain, and how aberrant neuroinflammation may render chronic pain intractable. For intractable pain, sleep and stress management are promising treatment options.

IMPLICATIONS

The authors hope that the present paper helps to stimulate the flexible creativity that is required to deal with the biological and psychological impact of PGP. Measuring inflammatory mediators in PGP should be a research priority. It should be understood that the boundaries between biology and psychology are becoming blurred. Clinicians must frequently monitor pain, disability, and mood, and be ready to switch treatment whenever the patient does not improve.

Understanding and managing pelvic girdle pain from a person-centred biopsychosocial perspective

INTRODUCTION

Clinicians need support to effectively implement a biopsychosocial approach to people with pelvic girdle pain disorders.

PURPOSE

A practical clinical framework aligned with a contemporary biopsychosocial approach is provided to help guide clinician's management of pelvic girdle pain. This approach is consistent with current pain science which helps to explain potential mechanistic links with co/multi-morbid conditions related to pelvic girdle pain. Further, this approach also aligns with the Common-Sense Model of Illness and provides insight into how an individual's illness perceptions can influence their emotional and behavioural response to their pain disorder. Communication is critical to supporting recovery and facilitating behaviour change within the biopsychosocial context and in this context, the patient interview is central to exploring the multidimensional nature of a persons' presentation. Focusing the biopsychosocial framework on targeted cognitive-functional therapy as a key component of care can help an individual with pelvic girdle pain make sense of their pain, build confidence and self-efficacy and facilitate positive behaviour and lifestyle change. There is growing evidence of the efficacy for this broader integrative approach, although large scale effectiveness trials are still needed. An in-depth case study provides guidance for clinicians, showing 'how to' implement these concepts into their own practice within a coherent practical framework.

IMPLICATIONS

This framework can give clinicians more confidence in understanding and managing pelvic girdle pain. The framework provides practical strategies to assist clinicians with implementation; assisting the transition from knowing to doing in an evidence-informed manner that resonates with real world practice.

Fear-avoidance beliefs: A predictor for postpartum lumbopelvic pain

OBJECTIVE

To evaluate potential prognostic factors of self-reported lumbopelvic pain 6 months postpartum for pregnant women with and without lumbopelvic pain.

METHODS

Questionnaires were answered at gestational weeks 34-37 and again at 6 months postpartum. Psychosocial determinants and lumbopelvic pain symptoms were investigated using a visual analogue scale to assess pain intensity, and further using the Disability Rating Index, the Nottingham Health Profile, the Pain Catastrophizing Scale and the Fear-Avoidance Beliefs Questionnaire. Logistic regression analysis was used to analyse the data.

RESULTS

Of the 260 women who answered the questionnaires on both occasions, 186 did not suffer from lumbopelvic pain 6 months after pregnancy. The remaining 74 did. The results of the logistic regression analysis showed that fear-avoidance beliefs was a significant predictor of lumbopelvic pain 6 months postpartum, with an odds ratio of 1.060 (p ≤ .05).

CONCLUSION

Women with high fear-avoidance beliefs at 34-37 weeks of gestation had a higher risk of having lumbopelvic pain at 6 months postpartum. We theorize that early lumbopelvic pain intervention postpartum may be important in avoiding chronicity. Women at risk can be identified through clinically relevant questions which may help the clinician to choose appropriate rehabilitation strategies.

Explicit and Implicit Own's Body and Space Perception in Painful Musculoskeletal Disorders and Rheumatic Diseases: A Systematic Scoping Review

Background: Pain and body perception are essentially two subjective mutually influencing experiences. However, in the field of musculoskeletal disorders and rheumatic diseases we lack of a comprehensive knowledge about the relationship between body perception dysfunctions and pain or disability. We systematically mapped the literature published about the topics of: (a) somatoperception; (b) body ownership; and (c) perception of space, analysing the relationship with pain and disability. The results were organized around the two main topics of the assessment and treatment of perceptual dysfunctions. Methods: This scoping review followed the six-stage methodology suggested by Arksey and O'Malley. Ten electronic databases and grey literature were systematically searched. The PRISMA Extension for Scoping Reviews was used for reporting results. Two reviewers with different background, independently performed study screening and selection, and one author performed data extraction, that was checked by a second reviewer. Results: Thirty-seven studies fulfilled the eligibility criteria. The majority of studies (68%) concerned the assessment methodology, and the remaining 32% investigated the effects of therapeutic interventions. Research designs, methodologies adopted, and settings varied considerably across studies. Evidence of distorted body experience were found mainly for explicit somatoperception, especially in studies adopting self-administered questionnaire and subjective measures, highlighting in some cases the presence of sub-groups with different perceptual features. Almost half of the intervention studies (42%) provided therapeutic approaches combining more than one perceptual task, or sensory-motor tasks together with perceptual strategies, thus it was difficult to estimate the relative effectiveness of each single therapeutic component. Conclusions: To our knowledge, this is the first attempt to systematically map and summarize this research area in the field of musculoskeletal disorders and rheumatic diseases. Although methodological limitations limit the validity of the evidence obtained, some strategies of assessment tested and therapeutic strategies proposed represent useful starting points for future research. This review highlights preliminary evidence, strengths, and limitations of the literature published about the research questions, identifying key points that remain opened to be addressed, and make suggestions for future research studies. Body representation, as well as pain perception and treatment, can be better understood if an enlarged perspective including body and space perception is considered.

Trajectories of lower back, upper back, and pelvic girdle pain during pregnancy and early postpartum in primiparous women

Objective:

Most studies about truncal pain during and after pregnancy focus on low back pain, few prospectively define change in pain, and even fewer evaluate pain in all three major truncal areas: upper back, lower back, and pelvic girdle. Thus, the objective of this prospective cohort study was to describe, in primiparous women delivered vaginally, prevalence rates and severities of upper back, lower back, and pelvic girdle pain during pregnancy and 6–10 weeks postpartum and to describe the trajectory of pain constellations between time points.

Study design:

Participants completed questionnaires at each time point. Pain intensity was rated on a visual analogue scale ranging from 0 to 100.

Results:

Of the 288 participants, 94% reported truncal pain during pregnancy, while 75% did so postpartum. Prevalence rates of upper back, lower back, and pelvic girdle pain with or without other types of pain during pregnancy were 42%, 77%, and 74% and postpartum were 43%, 52%, and 41%, respectively. Pain severity was highest for women endorsing pain in three locations (median 55–60). Of women with the most common pain constellation during pregnancy, lower back and pelvic girdle (32%), 18% had persistent low back and pelvic girdle pain postpartum, 20% had no pain, and the remainder had pain in a different location. Of women with pain in all three locations during pregnancy (27%), 34% had persistent pain in three locations postpartum, 13% had no pain, and the remainder had pain in at least one location.

Conclusion:

More women experience pain in a constellation of locations than in a single location. Severity increases as number of pain sites increase. Women with pain in three sites during pregnancy are least likely to have pain resolve. Interventions should focus on the entire trunk and not simply one site of pain.

Convergence and Divergence of Exercise-Based Approaches That Incorporate Motor Control for the Management of Low Back Pain

Many approaches for low back pain (LBP) management focus on modifying motor control, which refers to motor, sensory, and central processes for control of posture and movement. A common assumption across approaches is that the way an individual loads the spine by typical postures, movements, and muscle activation strategies contributes to LBP symptom onset, persistence, and recovery. However, there are also divergent features from one approach to another. This commentary presents key principles of 4 clinical physical therapy approaches, including how each incorporates motor control in LBP management, the convergence and divergence of these approaches, and how they interface with medical LBP management. The approaches considered are movement system impairment syndromes of the lumbar spine, Mechanical Diagnosis and Therapy, motor control training, and the integrated systems model. These were selected to represent the diversity of applications, including approaches using motor control as a central or an adjunct feature, and approaches that are evidence based or evidence informed. This identification of areas of convergence and divergence of approaches is designed to clarify the key aspects of each approach and thereby serve as a guide for the clinician and to provide a platform for considering a hybrid approach tailored to the individual patient. J Orthop Sports Phys Ther 2019;49(6):437-452. Epub 15 May 2019. doi:10.2519/jospt.2019.8451.

The Association of Variations in Hip and Pelvic Geometry With Pregnancy-Related Sacroiliac Joint Pain Based on a Longitudinal Analysis

STUDY DESIGN

Cross-sectional study using radiological measurements and longitudinal data analysis.

OBJECTIVE

We aim to explore hip/pelvic geometry on anteroposterior radiographs and examine if such parameters are associated with clinical symptoms.

SUMMARY OF BACKGROUND DATA

Pregnancy-related sacroiliac joint pain is a common disease and is responsible to the disability of daily activities. The etiology is likely to be correlated with the biomechanical factors which are determined by trunk load and hip/pelvic geometry. Previous studies have already found the association between symptoms and weight increase during pregnancy. However, the relationship between bony anatomy and pregnancy-related sacroiliac joint pain remains unknown.

METHODS

In total, 72 women were included in the final analysis. In pregnant women with self-reported sacroiliac joint pain, pain scores at 12, 24, 30, and 36 weeks of pregnancy were recorded and included in a mixed-effect linear regression model as dependent variables. The radiological measurements were included as independent variables. Furthermore, to investigate the relationship between hip/pelvic geometry and the activity-specific nociceptive phenomenon, the radiological measurements between patients with and without activity-induced pain were compared using a binominal logistic regression model.

RESULTS

The relative bilateral is chial tuberosity distance (betta coefficient: 0.078; P = 0.015) and the relative bilateral femoral head length (betta coefficient: 0.011; P = 0.028) showed significant interactions with the slope of pain scores. Moreover, women whose pain exacerbate during prolonged walking had a higher odds in hip/pelvic geometry of the bilateral ischial tuberosity distance (odds ratio [OR]: 1.12; P = 0.050) and the bilateral femoral head length (OR: 1.16; P = 0.076) with approximately significant P-value.

CONCLUSION

These data indicate hip/pelvic anatomical variations are associated with the degree of pain increasing and the activity-specific pain during pregnancy, which may help to have further understanding on the biomechanical factor in developing pregnancy-related sacroiliac joint pain.

LEVEL OF EVIDENCE

3.

Correlations between the active straight leg raise, sleep and somatosensory sensitivity during pregnancy with post-partum lumbopelvic pain: an initial exploration

Background and aims

For some women, lumbopelvic pain (LPP) developed during pregnancy becomes a continuing post-partum problem. Increased understanding of potential prognostic factors is required. This study investigated whether active straight leg raise (ASLR), sleep dysfunction and pressure pain sensitivity during pregnancy are correlated with LPP intensity and quality, disability, and physical health-related quality of life (HRQoL) post-partum.

Methods

An exploratory, prospective cohort study design was used. Baseline factors of interest were: (1) ASLR, (2) Pittsburgh Sleep Quality Index, and (3) pressure pain thresholds (PPTs) collected from pregnant women from sites local and distal to the lumbopelvic area. Follow-up data collected 11–18 months post-partum (n=29) were: (1) pain intensity score (numerical rating scale), (2) pain quality (McGill Pain Questionnaire), (3) disability (Pelvic Girdle Questionnaire), and (4) HRQoL (36-item Short Form Health Survey). Correlation analysis was performed.

Results

Greater difficulty with an ASLR during pregnancy correlated with lower post-partum physical HRQoL scores (r=−0.563, p=0.002). Likewise, reduced PPTs at the sacrum during pregnancy was correlated with a higher post-partum pain quality score (r=−0.384, p=0.040).

Conclusions

In this cohort, findings indicate that poor ASLR performance and localised pressure pain hypersensitivity at the pelvis during pregnancy are correlated with post-partum physical HRQoL and pain quality, respectively.

Implications

Pain sensitivity may contribute to the prognosis of women with LPP during pregnancy. These explorative findings may be important for designing larger prognostic studies and may assist in directing potential pain management in post-partum LPP.

Does muscle energy technique have an immediate benefit for women with pregnancy-related pelvic girdle pain?

OBJECTIVE

Pregnancy-related pelvic girdle pain (PPGP) is a common and debilitating condition. Muscle energy techniques (METs) are used in the management of PPGP. This study aimed to determine the immediate effectiveness of a MET in the management of pain in women with PPGP within a single session of physiotherapy.

METHODS

This study was a randomized, crossover, sham-controlled trial. Women (N = 80), M (SD), 30 (5) years of age and 29 (5) weeks of gestation with PPGP were included in the study. All participants were treated with a MET and sham transcutaneous electrical nerve stimulation in a randomized order, followed by standard physiotherapy during a single physiotherapy session. The primary outcome measures were the self-report of pain using a visual analogue scale and function using the Timed Up and Go. The secondary outcome was the duration of single leg stance (SLS). Clinical measures were taken prior to the first intervention and immediately following each of the interventions, a total of four times.

RESULTS

There was no statistically significant difference between scores for the visual analogue scale, Timed Up and Go, or duration of SLS between participants following the use of a MET, sham transcutaneous electrical nerve stimulation, or standard care, which was recorded after each intervention (p ≥ 0.72). There was a consistent and statistically significant (p value, mean difference) improvement in pain (p < 0.001, 2.6), function (p < 0.001, 1.0 s), and left SLS (p < 0.001, 4.4 s) and right SLS (p < 0.001, 4.7 s) from baseline compared with each time of measurement thereafter.

CONCLUSIONS

The improvements measured may have been due to a placebo effect with the knowledge that care is being provided, mechanical unloading during the session, or familiarization with the test procedures. The mechanism(s) that led to improvements in pain and function remain unknown, however, does not preclude from women with PPGP being offered physiotherapy care.

The development of the Dutch version of the Fremantle Back Awareness Questionnaire

BACKGROUND

Disturbed body perception may play a role in the aetiology of chronic low back pain (LBP). The Fremantle Back Awareness Questionnaire (FreBAQ) is currently the only self-report questionnaire to assess back-specific body perception in individuals with LBP.

OBJECTIVES

To perform a cross-cultural adaptation of the FreBAQ into Dutch.

DESIGN

Psychometric study.

METHODS

A Dutch version of the FreBAQ was generated through forward-backward translation, and was completed by 73 patients with LBP and 73 controls to assess discriminant validity. Structural validity was assessed by principal component analysis. Internal consistency was assessed by the Cronbach's alpha coefficient. Construct validity was assessed by examining the relationship with clinical measures (Numerical Rating Scale pain, Oswestry Disability Index (ODI), Tampa Scale for Kinesiophobia). Test-retest reliability was assessed in a subgroup (n = 48 with LBP and 48 controls) using intraclass correlation coefficients (ICC), standard error of measurement (SEM) and minimal detectable change (MDC 95%) RESULTS: The Dutch FreBAQ showed one component with eigenvalue >2. Cronbach's alpha values were respectively 0.82 and 0.73 for the LBP and control group. ICC values were respectively 0.69 and 0.70 for the LBP and control group. In the LBP group, the SEM was 3.9 and the MDC (95%) was 10.8. The LBP group (ODI 22 ± 21%) scored significantly higher on the Dutch FreBAQ than the control group (ODI 0%) (11 ± 7 vs. 3 ± 9, p < 0.001). Within the LBP group, higher Dutch FreBAQ scores correlated significantly with higher ODI scores (rho = 0.30, p = 0.010), although not with pain (rho = 0.10, p = 0.419) or kinesiophobia (r = 0.14, p = 0.226).

CONCLUSIONS

The Dutch version of the FreBAQ can be considered as unidimensional and showed adequate internal consistency, sufficient test-retest reliability and adequate discriminant and construct validity in individuals with and without LBP. It can improve our understanding on back-specific perception in the Dutch-speaking population with LBP.

Disrupted body-image and pregnancy-related lumbopelvic pain. A preliminary investigation

BACKGROUND

Recent investigations have suggested that disrupted body-image may contribute to the lumbopelvic pain experience. The changes in body shape and size associated with pregnancy suggest that pregnancy-related lumbopelvic pain might be a problem in which alterations in body-image are particularly relevant.

OBJECTIVES

To investigate if self-reported body-image is related to lumbopelvic pain status in women during pregnancy and explore the factors that might contribute to changes in body-image in women experiencing pregnancy-related lumbopelvic pain.

DESIGN

Cross-sectional cohort study.

METHOD

Forty-two women in the third trimester of pregnancy were recruited regardless of clinical status. Pain intensity and disability were measured to estimate clinical severity. The Fremantle Back Awareness Questionnaire was used to assess body-image. Participants also completed a series of questionnaires and physical tests to explore factors that might be associated with altered body-image.

RESULTS

The median Fremantle Back Awareness Questionnaire score for the pain free women was 1 (IQR 0-1.5) and the median score for those in pain was 3.5 (IQR 2-8). This difference was statistically significant (p = 0.005). The questionnaire score was significantly correlated with pain intensity but not with disability. Of the measured variables only pain catastrophisation was significantly associated with disrupted body-image.

CONCLUSIONS

Self-reported disruption of body-image was significantly greater in pregnant women who were experiencing lumbopelvic pain than those who weren't and the extent of body-image disruption was associated with pain intensity. Only pain related catastrophisation was related to disrupted body-image.