New Perspectives. Gestational Biomechanics & Axial Pain. Greg Whitcomb DC Assistant Professor Department of Neurosurgery Medical College of Wisconsin

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1 New Perspectives Gestational Biomechanics & Axial Pain Greg Whitcomb DC Assistant Professor Department of Neurosurgery Medical College of Wisconsin

2 Nothing to disclose Disclosure

3 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

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

5 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 Vleeming A et al Churchill Livingstone Elsevier Publishers 2007

6 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

7 Compound Restraint Mechanisms Lumbar Ligaments and Disc Also Resist Sheer Forces

8 A Word About SI Joints. SI Motion is Present but MM SIJ Mobility % > 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

9 Stability is Controlled in Multiple Planes The Low Back, Pelvis Are Dependent on Muscular Stability for Controlled Motion & Load Distribution

10 a Sexual Dimorphism of the L3 Vertebral Body Fetal Load & The Evolution of Lumbar Lordosis in Bipedal Hominins Whitcome K et al Nature 450, (13 December 2007)

11 a Center of Mass Fluctuates Substantially a a a a a Whitcome K et al Nature 450, (13 December 2007)

12 a Cost To Stabilize COM Nearly 60% Increase in Lordosis & Resultant Sheer on Lumbar Facet Joints

13 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 Love T W Degenerative Spondylolisthesis: Developmental or Acquired?. JBJS Br;82(2):307-8; 2000

14 Risk Factors for Degenerative Spondylolisthesis: A Systematic Review Female Gender & Higher Facet Joint Angle Consistently Associated With an Increased Risk of DS Across Multiple Studies Devine A et al Evidence-Based Spine Journal 3(2):25-34; 2012

15 Form Closure Force Closure

16 Global Muscular Stabilization of the Spine & Pelvis Van Windergarden JP et al European Spine Journal 2;140-44, 1993

18 Moving Differently in Pain: A New Theory to Explain the Adaptation to Pain Hodges P, Tucker K - PAIN 152:3 Suppl;S90-8, 2011

19 Altered Motor Control Strategies in Subjects With SI Joint Pain During the Active Straight-Leg-Raise Test Respiratory Patterns Recorded With Spirometry With Minute Ventilation Diaphragmatic Excursion and Pelvic Floor Descent Measured With Ultrasonography 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 O Sullivan P et al SPINE Vol 27(1):E1-E8; 2002

20 Relations Between PRLBP Pelvic Floor Activity & Dysfunction 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 Pool-Goudzwaard et al Int Urogyn Journal Pelvic Floor Dysfunction 2005;16(6):468-74

21 Validity of the Active SLR For Measuring Disease Severity in Patients With Posterior Pelvic Pain After Pregnancy Mens A et al SPINE 27(2): ; 2002

22 Remember, Balance is the Key to Life!!

23 Manipulation & Mobilization No Evidence Bracing Limited to No Evidence Activity Modification Not Studied European Guidelines For the Diagnosis & Treatment of Pelvic Girdle Pain Eur Spine J Jun;17(6):820-1; 2008

24 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 Pickar J - The Spine Journal 2002 Haavik-Taylor H Clinical Neurophysiology 2007 Dishman D The Spine Journal 2003

25 BETTER WHEN COMBINED WITH EXERCISE 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); , 2002

26 IN SUMMARY 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!!

27 Treatment Effect Versus Rehab Effect

28 OH, MY ACHING BUTT! WHAT CAN IT HURT?

29 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 Stuge B et al SPINE Vol 29(4):351-59; 2004

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

32 Thank You Dr. Jones And MCW OB/GYN!

Stress Urinary Incontinence & The Pelvis

Stress Urinary Incontinence & The Pelvis Updated January 2011 by Diane Lee Introduction The research in the last decade has led to a clearer understanding of how load is transferred through the low back