Low Back Pain Disability During Pregnancy Evaluated by Oswestry
L. Doug Adair DC #, Mark A. Wyatt DC #, Clayton Skaggs DC# @, Lorrie A. Mason MSN *, and Terry Williams DO +, Joseph H. Kipikasa MD + *, C. David Adair MD + *,
+ Department of Obstetrics and Gynecology
University of Tennessee School of Medicine, Chattanooga Unit
Chattanooga, TN 37403
* Regional Obstetrical Consultants
Chattanooga, TN 37403
# Department of Clinical Sciences
Logan College of Chiropractic
St. Louis, MO 63006
@ Department of Obstetrics and Gynecology
Washington University School of Medicine
St. Louis, MO 63110
Corresponding Author: Doug Adair and Mark Wyatt
Logan College of Chiropractic
St. Louis, MO 63006
Objective: The objective of this study is to evaluate the self-reported disability due to low back pain during pregnancy by using the Oswestry Low Back Pain Disability Index.
Methods: This is an analytical study designed to determine the severity of self-reported disability during pregnancy for 301 women. Participants were recruited from attendees of the University of Tennessee Obstetrical Clinic (Chattanooga Unit) and Regional Obstetrical Consultants, Department of Maternal/Fetal Medicine Clinic in the city of Chattanooga, TN. Women completed a questionnaire on the initial visit to the high-risk pregnancy clinic.
Results: Two hundred eighty three of the three hundred one participants completed the survey, which correlates to a 94.02 % response rate. Twenty-nine of the two hundred eighty three participants (10.247 %) reported a score that correlated to no disability and ninety-two participants (32.509 %) reported a score that correlated to mild disability. On the other hand, one hundred seven participants (37.809 %) reported a score that correlated to moderate disability, forty-nine participants (17.314 %) reported a score that correlated to severe disability and six participants (2.120 %) reported a score that correlated to complete disability.
Conclusion: In this cohort of pregnant women, the majority of pregnant women experience low back pain to the extent of considerable disability.
For the majority of pregnant women, low back pain is very common during pregnancy. "Recent literature suggests that around half of all pregnant women incur lumbopelvic pain, which may persist, or arise, after delivery, and will, in some patients, lead to severe disability (1,3,4,5,6,7,8,9,10,11,12)." According to Mogren's study of Low back pain during pregnancy, many studies showed the prevalence of low back pain during pregnancy to be 24 % - 90%. It was also found that 1/3 had back pain that was severe enough to compromise daily living. Low back pain during pregnancy is a most common complication. Its etiology and pathophysiology are understudied and therefore poorly understood. A common theory for low back pain during pregnancy is due to the decreased stability of the pelvic girdle with the increase in spinal load (18).
In this study we are proposing that a majority of pregnant women are severely affected by low back to a degree that it affects the activities of daily living to a rating of at least moderate disability on the ODQ scale. Low back pain during pregnancy can originate from multiple sites. The most common origins of pain are the facet joints, para-spinal muscles, supporting ligaments, or discogenic sources. In the lumbar spine, joint laxity is most notable in the anterior and posterior longitudinal ligaments, both of which are pain sensitive structures. Discogenic symptoms and/or pain from the facet joints may increase as the static supports in the lumbar spine become more lax. As accommodation for the growing fetus occurs, the abdominal muscles often stretch past their ability to help fully stabilize the pelvis. Lumbar para-spinal muscles pick up the burden of support, which may already be in a taut state (13). These pain centers are activated with an increase in lordosis of the lumbar spine as seen with a gravid uterus as it accentuates an anterior pelvic tilt. With progression of the pregnancy, hyperlordosis and forward rotation along the x-axis of the lumbar spine increase as sacroiliac ligaments become relaxed by the effect of relaxin. These events cause an increased mechanical strain of the low back, pelvis and Sacroiliac joints along with the fore mentioned pain generating sites (19).
The information obtained from this ODQ study, along with the few other studies associated with low back pain during pregnancy, may be used to validate the existence of pain related disability during pregnancy. The Oswestry Low Back Pain Disability Questionnaire (ODQ) is a widely used, ten-question paper and pencil measure of disability resulting from low back pain. With pain being a subjective perception, it is a measurement of impairment rather than a disability. This makes it important for tools used to measure disability to include patient reaction to limitations imposed by the condition in order to accurately assess its impact. The oswestry low back pain disability questionnaire is a potential value in this regard. The ODQ is an ordinary rating scale of daily living functional disabilities resulting from back pain that attempts to measure handicap and disability of pain rather than focusing on the nature of the pain (14,15,16). The validity of the ODQ was shown in Tibbles' study on the validity of the Oswestry Low Back Pain Disability Questionnaire, which concluded that the ODQ appeared to possess stable psychometric properties (17). One would have to consider the oswestry index system of utmost reliability considering that Mannion demonstrated an intraclass correlation coefficient for the test retest reliability of the questionnaire at .96 reliability even after cross cultural adaptation into Germany (20).
The protocol was approved by the institutional review board of the University of Tennessee School of Medicine (Chattanooga Unit) and was compliant with HIPAA rules. This in an analytical study designed to determine the severity and prevalence of self reported activity restrictions in order to determine a level of disability. Participants in this study were recruited at the University of Tennessee's School of Obstetrics and Gynecology and the office of Regional Obstetrical Consultants, both in Chattanooga, TN. The university clinic is staffed faculty in the Department of Obstetrics and Gynecology and the Department of Maternal/Fetal Medicine. The University OB clinic serves an array of patients in varying socioeconomic status. The University clinic is staffed by attending physicians from the University of Tennessee Department of Obstetrics and Gynecology and Residents in Obstetrics and Gynecology. Regional Obstetrical Consultants is staffed by Maternal/Fetal Medicine physicians with residents in attendance.
After completing an informed consent form, surveys were offered to all obstetrical patients at their initial consultation (See Appendix A, Page 9 and 10). As part of routine obstetrical care, women were given the Oswestry questionnaire in order to collect information about pregnancy related pain and disability. Data was then totaled and percentages calculated using excel spread- sheets.
Ninety-four percent (283/301) of the women that participated in the study complied with the request to complete the Oswestry questionnaire. Eighteen participants did not complete all components of the questionnaire. Two hundred eighty three participants completed the questionnaire and were analyzed. The following disability indices were categorized according to the ranges derived by the Oswestry Disability Index (ODI) as designed by J. Fairbank. The average disability index was 32.99, which falls within the range of moderate disability (30 - 48 index score). Twenty-nine of the two hundred eighty three participants (10.247 %) reported a score that correlated to no disability (0 - 8 index score). Ninety-two participants (32.509 %) reported a score that correlated to mild disability (10 - 28 index score). One hundred seven participants (37.809 %) reported a score that correlated to moderate disability (30 - 48 index score). Forty-nine participants (17.314 %) reported a score that correlated to severe disability (50 - 68 index score) and six participants (2.120 %) reported a score that correlated to complete disability (above 68 index score).
The data from this study demonstrates a significant impact on the activities of daily living and in this population of pregnant women more than half (57.243%) of all participants demonstrate lumbopelvic pain syndromes leading to severe disability. Of the remaining participants (42.757%), the majority (32.509%) reported a score that correlated to at least slight disability, and only 10.247% reported a score that correlated to no disability. The incidence of low-back pain in pregnancy has been very limited. However, in a study conducted by Colliton, "the overall prevalence of back pain during the 9-month period is thought to be approximately 50% (21,22)." Another study by Borg-Stein, Dugan, and Gruber suggests that virtually all women experience some degree of musculoskeletal discomfort during pregnancy, and 25% have at least temporarily disabling symptoms (x). Mogren's study showed the prevalence of LBPP during pregnancy was 72%(x). However, the results of this study reveals disability due to low back pain to be present in a higher percentage (89.753%) demonstrating disability (including mild, moderate, severe, and complete disabilities per ODI scale).
The importance of this study is to assist in documenting the existence and prevalence of pain induced disability among pregnant women. As the prevalence of low back pain during pregnancy becomes known, mothers to be may consider physical conditioning before becoming pregnant. Also, as data continues to prove the prevalence of pain-induced disability during pregnancy, measures may be developed by care givers to decrease the percentage of disability.
The average disability index in this population of pregnant women was 32.99 indicating a striking effect on activities of daily living and according to this survey, 57.243 % of pregnant women experience moderate to complete disability with and index score ranging from 30 - above 68. Although this area of study has gained some recognition recently, it is still considered unrecognized. We feel this study demonstrates that pregnant women may indeed suffer disability and often to a severe degree that may have chronic pain implications.
Please Read: This questionnaire is designed to enable us to understand how much your low back has affected your ability to manage everyday activities. Please answer each Section by circling the ONE CHOICE that most applies to you. We realize that you may feel that more than one statement may relate to you, but Please just circle the one choice which closely describes your problem right now.
SECTION 1--Pain Intensity
- The pain comes and goes and is very mild.
- The pain is mild and does not vary much.
- The pain comes and goes and is moderate.
- The pain is moderate and does not vary much.
- The pain is severe but comes and goes.
- The pain is severe and does not vary much.
SECTION 2--Personal Care
- I would not have to change my way of washing or dressing in order to avoid pain.
- I do not normally change my way of washing or dressing even though it causes some pain.
- Washing and dressing increase the pain, but I manage not to change my way of doing it.
- Washing and dressing increase the pain and I it necessary to change my way of doing it.
- Because of the pain, I am unable to do any washing and dressing without help.
- Because of the pain, I am unable to do any washing or dressing without help.
- I can lift heavy weights without extra pain.
- I can lift heavy weights, but it causes extra pain.
- Pain prevents me from lifting heavy weights off the floor.
- Pain prevents me from lifting heavy weights off the floor, but I can manage if they are conveniently positioned, e.g. on the table.
- Pain prevents me from lifting heavy weights, but I can manage light to medium weights if they are conveniently positioned.
- I can only lift very light weights, at the most.
SECTION 4 --Walking
- Pain does not prevent me from walking any distance.
- I have some pain with walking but it does not increase with distance.
- Pain prevents me from walking more than one mile.
- Pain prevents me from walking more than 1/2 mile.
- I can only walk while using a cane or on crutches.
- I am in bed most of the time and have to crawl to the toilet.
- 1 can sit in any chair as long as I like without pain.
- I can only sit in my favorite chair as long as I like.
- Pain prevents me from sitting more than one hour.
- Pain prevents me from sitting more than 1/2 hour.
- Pain prevents me from sitting more than ten minutes.
- Pain pevents me from sitting at all.
- I can stand as long as I want without pain
- I have some pain while standing, but it does not increase with time.
- I cannot stand for longer than one hour without increasing pain.
- I cannot stand for longer than 1/2 hour without increasing pain.
- I can't stand for more than 10 minutes without increasing pain.
- I avoid standing because it increases pain right away.
- I get no pain in bed.
- I get pain in bed, but it does not prevent me from sleeping.
- Because of pain , my normal night's sleep is reduced by less than one-quarter.
- Because of pain, my normal night's sleep is reduced by less than one-half.
- Because of pain, my normal night's sleep is reduced by less than three-quarters.
- Pain prevents me from sleeping at all.
SECTION 8--Social Life
- My social life is normal and gives me no pain.
- My social life is normal, but increases the degree of my pain.
- Pain has no significant effect on my social life apart from limiting my more energetic interests, e.g., dancing, etc.
- Pain has restricted my social life and I do not go out very often.
- Pain has restricted my social, life to my home.
- Pain prevents me from social, life at all.
- I get no pain while traveling.
- I get some pain while traveling, but none of my usual forms of travel make it any worse.
- I get extra pain while traveling, but it does not compel me to seek alternative forms of travel.
- I get extra pain while traveling which compels me to seek alternative forms of travel.
- Pain restricts all forms off travel.
- Pain prevents all forms of travel except that done lying down.
SECTION 10--Changing Degree of Pain
- My pain is rapidly getting better.
- My pain fluctuates, but overall is definitely getting better.
- My pain seems to be getting better, but improvement is slow at present.
- My pain is neither getting better nor worse.
- My pain is gradually worsening.
- My pain is rapidly worsening.
Disability index score:________ %
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