CLINICAL ARTICLE

The effect of epain in pregnan

A. Garshasbia,*, S. Fa

aDepartment of Obstetrics andbDepartment of Bio Statistics,

Received 13 August 2004; receive

questionnaire between 1722 weeks of gestation and 12 weeks later for assess-ment of their back pain intensity. Lordosis and flexibility of spine were measured

different between the two groups. Conclusion: Exercise during second half of the

Ireland Ltd. All rights reserved.

normal pregnancy. Several studies have shown thatat least 50% of women experience some kind of

KEYWORDSExercise;Flexibility;Lordosis;Low back pain;Pregnancy;Spine

International Journal of Gynecology and Obstetrics (2005) 88, 271275* Corresponding author. Tel.: +98 218830160; fax: +98218829142.1. Introduction

Back pain during pregnancy is a common conditionoften regarded as an unavoidable drawback of apregnancy significantly reduced the intensity of low back pain, had no detectableeffect on Lordosis and had significant effect on flexibility of spine.D 2004 International Federation of Gynecology and Obstetrics. Published by Elsevierby Flexible ruler and Side bending test, respectively, at the same times. Weightgain during pregnancy, Pregnancy length and neonatal weight were recorded.Result: Low back pain intensity was increased in the control group. The exercisegroup showed significant reduction in the intensity of low back pain after exercise( pb0.0001). Flexibility of spine decreased more in the exercise group ( pb0.0001).Weight gain during pregnancy, pregnancy length and neonatal weight were not0020-7292/$ - see front matter D 200All rights reserved.doi:10.1016/j.ijgo.2004.12.001

E-mail address: ahiagarshasbi@obgxercise on the intensity of low backt women

ghih Zadehb

Gynecology, Shahed University, Faculty of Medicine, 1481973411 Tehran, IranTarbiat Modaress University, Faculty of Medical Sciences, Tehran, Iran

d in revised form 29 November 2004; accepted 29 November 2004

Abstract

Objective: To investigate the effect of exercise during pregnancy on the intensityof low back pain and kinematics of spine. Method: A prospective randomized studywas deigned. 107 women participated in an exercise program three times a weekduring second half of pregnancy for 12 weeks and 105 as control group. All filled a4 International Federation of

yn.net (A. Garshasbi).www.elsevier.com/locate/ijgoback pain during some period of pregnancy [17].

Gynecology and Obstetrics. Published by Elsevier Ireland Ltd.

have been focused on changed load resulting from

aerobic exercise during pregnancy according toACOG new guidelines in 2002; history of exercisebefore pregnancy and history of orthopedic diseaseor surgery were excluded. Using sealed envelopes,the women who accepted the offer were random-ized into two groups; one group was offered toexercise three times a week for 12 weeks, the othergroup was not. The total number of women in theexercise and control groups were 107 and 105,

A. Garshasbi, S. Faghih Zadeh272increased weight and decreased stability of thepelvic girdle due to hormonal changes [8,9]. Somestudies have revealed a correlation between circu-lating levels of the hormone relaxin and pelvic painin pregnancy, while others have found no suchcorrelation [8,9].

Back pain affects daily activities and accountsfor most of the sick leave among pregnantwomen in Scandinavian countries [10]. Preventionand treatment of back pain related to pregnancywould thus have considerable implications for thewomen themselves and for the society in termsof quality of life, public health costs andproductivity [11,12].

Exercise is becoming increasingly popular duringpregnancy. One goal of exercise during pregnancyis to restore optimal biomechanics [13]. Lumbo-pelvic stabilization may be achieved by exerciseaiming at appropriate posture and enhancedmuscle function. No study has shown significanteffects of exercise on back pain during pregnancy.

The purpose of the present study was to evaluatethe effectiveness of special exercise during preg-nancy in preventing or reducing low back pain.

2. Materials and methods

2.1. Study population and design

A prospective randomized study was carried outbetween April 2003 and January 2004 at Departmentof Obstetrics and Gynecology, Hazrat Zaynb Hospi-Ostgaard et al. showed that rate of these compli-cations in athletic women was less than nonathleticwomen [7]. Meanwhile it is not obvious that innonathletic pregnant women, exercise can reducethe intensity of low back pain.

The etiology and pathogenesis of back painrelated to pregnancy is unclear. Most hypotheses

Table 1 Characteristics of study population

Exercisegroup N=107

Controlgroup N=105

p-value

Age (yearsFS.D.) 26.27F4.87 26.48F4.43 0.432Weight (kgFS.D.) 67.08F12.8 55.42F12.90 0.171Height (cmFS.D.) 160.75F5.64 159.87F6.55 0.646BMI (kg/m2) 25.98F4.82 25.58F5.12 0.603tal, Tehran, Iran. The Ethics Committee of theMedical Faculty approved it at Shahed University.Women who were primigravid, between 20 and 28years old, 1722nd weeks of gestation, housewivesand were high school graduated were given oppor-tunity to participate in the present study. Womenwith any absolute and relative contraindications torespectively. All the women in the exercise groupwere informed about warning signs according toACOG guidelines, to terminate exercise and beingexcluded from study. All women gave their informedconsent.

2.2. The questionnaire

The women in the exercise and control group wereasked to fill a questionnaire. This questionnairefocused on low back pain according to KEBKquestionnaire, which was changed according toIranian culture and behaviors. The KEBK question-naire had 25 questions and every question wasscored between 0 (without pain), 1 (mild pain), 2(moderate pain), 3 (severe pain), 4 (very severepain). Womens total score considered equal totheir low back pain intensity.

Data about age, height, prepregnancy weightand BMI was also given.

The second KEBEK questionnaire was completedafter ending the exercise in the exercise group andafter 12 weeks in the control group.

Flexibility of spine on the left and the right sidewas measured by Side Bending Test. Lordosis angleof lumbar spine was measured by Flexible ruler(Fiskars, USA). The two measurements wererepeated in the two groups at the same time thatsecond questionnaire was completed.

Data about weight gain during pregnancy, gesta-tional age at delivery and neonatal weight wasrecorded.

2.3. The exercise programs

This program was scheduled for strengthening ofabdominal muscles, Hamstrings muscles and to

Table 2 Low back pain in study population andeffect of exercise on it

Low back pain Exercisegroup N=107

Controlgroup N=105

p-value

Before exercise 23.60F18.09 31.63F20 0.484After exercise 30.48F15.46 33F20.39 0.006

pb0.001 pb0.001

increase traction of Iliopsoas and Para vertebralmuscles.

The exercise programs were included 15 move-ments in 60 min. These movements were: 5 minof slow walking, 5 min of extension movements,

by physiotherapists. The women were offered to

Hazrat Zaynab prenatal clinic during the studyperiod. Two hundred and eighty women wereinvited to participate in the study. Sixty of thesewomen were declined from participation since theycould not take part in the exercise group. Fourteenwomen could not participate because of recurrent

Table 3 Lordosis of spine in study population andeffect of exercise on it

Lordosis Exercisegroup N=107

Controlgroup N=105

p-value

Before exercise 45.65F3.05 35.36F3.06 0.949After exercise 39.15F4.89 40.44F4.04 0.887

pb0.001 pb0.001

Table 5 Maternal weight gain and pregnancy outcome

Group N MeanFS.D. p-value

Weight gain duringpregnancy (kg)

Exercise 107 14.1F3.8 0.63Control 105 13.8F5.2

Pregnancy length(weeks)

Exercise 107 38.2F3.3 0.51Control 105 38.4F2.7

Weight of theneonate (g)

Exercise 107 3426F675 0.82Control 105 3500F431

40.00Lord

o

The effect of exercise on the intensity of low back pain in pregnant women 273exercise three times a week. A midwife super-vised all women. The intensity of the exercisewas controlled by maternal pulse rate. For pulserates exceeding 140 per minute, the exercisestopped. Every woman who missed three sessionswas excluded from the study.

2.4. Statistical analysis

Results were analyzed using the SPSS for Windows.Comparisons between the exercise group and thecontrol group were carried out using t-Test, FishersExact Test and Chi-Square-Test. To analyze the lowback pain intensity before and after exercise,McNemar Test was used. The Wilcoxon was usedfor analysis of low back pain between the twogroups. A p value smaller than 0.05 was consideredsignificant.

3. Results

A number of 2358 primigravida pregnant womenwho had the conditions of the study registered at

Table 4 Spine flexibility in study population andeffect of exercise on it

Flexibility Exercisegroup N=107

Controlgroup N=105

p-valueand 10 min of general warming up, 15 min ofanaerobic exercise, 20 min of specific exerciseand 5 min return to the first position. Theexercises were recommended by Tarbiat ModaresFaculty of Sport and tested for pregnant womenRight sideBefore exercise 19.27F3.26 19.05F2.46 0.837After exercise 12.91F4.09 14.56F4.47 0.013

pb0.001 pb0.001Left sideBefore exercise 18.81F3.06 18.60F3.59 0.884After exercise 12.58F4.17 14.12F4.45 0.003

pb0.001 pb0.001urinary tract infection, threatened abortion andlack of time. Of the remaining 266 women, 161were randomized to the exercise group and 105women to the control group. All women in the twogroups answered the questionnaire. Fifty-fourwomen in the exercise group were excluded dueto exclusion criteria of study.

The mean age was 26 in the two groups. Therewere no differences between the two groupsregarding age, weight, height and BMI (Table 1).

In the exercise group 73 women (68%) and in thecontrol group 78 women (70.5%) experienced somekind of low back pain during pregnancy.

Intensity of low back pain in the exercise groupbefore and after exercise was significantly dec-reased, but in the control group, it was increased(Table 2).

Lordosis was significantly increased in the twogroups with no major differences between the twogroups (Table 3).

Flexibility that was measured on both sides ofspine before exercise in the two groups was notsignificantly different. After ending the exercise,flexibility of spine in the two groups was signifi-

50.00

45.00

a6.2 = 24.67 + 0.57 * bmi1 R-Square = 0.45

Linear Regression

sis35.00

20.00 30.00BMI(kg/m2)

40.00

Figure 1 Correlation between body mass index andLordosis.

gain, pregnancy length and neonatal weight

A. Garshasbi, S. Faghih Zadeh274(Table 5).The correlation between age, height, weight,

BMI, lordosis and flexibility of spine with low backpain was analyzed. There was weak correlationbetween weight (r=0.04, pb0.03), BMI (r=0.04,pb0.03), spine flexibility (r=0.06, pb0.01) andlordosis (r=0.05, pb0.02) with low back pain.

There is strong correlation between lordosis(r=0.45, pb0.000) (Fig. 1) and spine flexibility(r=0.44, pb0.000) (Fig. 2) with BMI.

In the exercise group, 90% of women said theywanted to do the same exercise in their nextpregnancy and will advise other pregnant womento exercise.

4. Discussion

This is the first study that shows the effect ofcantly decreased, and there was significant differ-ence between the two groups (Table 4).

There was no significant difference betweenthe two groups according to maternal weight

15.00

10.00

5.00

0.0020.00

Linear Regression

30.00

a5.2.2 = 27.24 + -0.58 * bmi1 R-Square = 0.44

BMI (kg/m2)

Spin

e Fl

exib

ility

40.00

Figure 2 Correlation between body mass index andspine flexibility.exercise on pregnant womens low back pain withdeletion of any variables. No difference wasshowed in pain intensity between the women inthe two groups at the beginning of the study.After ending the exercise programs, women inthe exercise group showed lower intensity of lowback pain in comparison to the beginning ofstudy. In the control group, intensity of low backpain increased as pregnancy advanced. As notedearlier subjects were randomly assigned in to thetwo groups, also the physiotherapist who meas-ured the variables was blinded to the groups andthe results of low back pain intensity. All womenwere primigravida housewives. As a result, theexercise can reduce the intensity of low backpain.References

[1] Bjorklund K, Bergstrom S. Is pelvic pain in pregnancywelfare compliant? Acta Obstet Gynecol Scand 2000;79:2430.

[2] Ostgaard HC, Andersson GBJ, Karlsson K. Prevalence ofback pain in pregnancy. Spine 1991;16:54952.

[3] Svensson HO, Andersson GBJ, Hagstad A, Jansson PO. Therelationship of low-back pain to pregnancy and gynecologicfactors. Spine 1990;15:3715.

[4] Noren L, Ostgaard S, Johansson G, Ostgaard HC. Lumbarback and posterior pelvic pain during pregnancy: a 3-yearfollow-up. Eur J Spine 2002 (Jun.);11(3):26771 [Electronicpublication 2001 Dec 08].

[5] Kristiansson P, Svardsudd K, Von Schoultz B. Back painduring pregnancy: a prospective study. Spine 1996;21:7029.

[6] Endressen EH. Pelvic pain and low back pain in pregnantwomenan epidemiological study. Scand J Rheumatol1995;24:13541.

[7] Ostgaard HC, Andersson GBJ, Schultz AB, Miller JAA.Influence of some biomechanical factors on low back painin pregnancy. Spine 1993;18:615.

[8] Kristiansson P, Svardsudd K, Von Scholtz B. Serum relaxin,symphyseal pain, and back pain during pregnancy. Am JObstet Gynecol 1996;175:13247.

[9] Petersen LK, Hvidman L, Uldbjerg N. Normal serum relaxinin women with disabling pelvic pain during pregnancy.Gynecol Obstet Invest 1994;38:213.

[10] Noren L, Ostgaard S, Nielsen TF, Ostgaard HC. Reduction ofsick leaves for lumbar back and posterior pelvic pain inpregnancy. Spine 1997;22:215760.The results of this study are similar to theresults of other studies regarding frequency oflow back pain during pregnancy: 7074% ofpregnant women experienced some kind of lowback pain during some periods of their pregnancy[6,7].

The biomechanical factors that were meas-ured in this study provided little explanation ofthe causes of low back pain during pregnancy.The same result was obtained by Ostgaard etal., who only found lordosis and abdominaldiameters to be related to back pain, but thecorrelations were weak [7]. In this study,increased lordosis had weak correlation withlow back pain. The exercise in this study didnot have any affect on lordosis. Dumas et al.found that exercise had no detectable effect onlordosis during pregnancy [14].

A positive correlation between increased flexi-bility and low back pain was observed, suggestingthat when weight increases, some instability mayoccur in the sacroiliac joint.

In conclusion, the results of this study suggeststhat exercise during the second and beginning of thethird trimester of pregnancy could reduce theintensity of low back pain and increase flexibilityof spine.

[11] Noren L, Ostgaard S, Nielsen TF, Ostgaard HC. Reduction ofsick leaves for lumbar back and posterior pelvic pain inpregnancy. Spine 1994;19(8):894900.

[12] Ostgaard HC, Zetherstrom G, Roos-Hansson E, Svanberg B.Reduction of back and posterior pelvic pain in pregnancy.Spine 1994;19:894900.

[13] ACOG Committee. Opinion no. 267: exercise during preg-nancy and the postpartum period. Obstet Gynecol 2002;99:1713.

[14] Dumas GA, Reid JG, Wolfe LA, Griffin MP, McGrath MJ.Exercise, posture and back pain during pregnancy, part 2:exercise and back pain. Clin Biomech 1995;10:1049.

The effect of exercise on the intensity of low back pain in pregnant women 275

The effect of exercise on the intensity of low back pain in pregnant womenIntroductionMaterials and methodsStudy population and designThe questionnaireThe exercise programsStatistical analysis

ResultsDiscussionReferences