History and Presenting Symptoms
A 33-year-old female reports the recent onset of persistent aching pain and tightness in her lower back region. The pain extends into both buttocks, and occasionally is felt around the left hip and into the left groin. She is into her 7th month of her second pregnancy, and says that her back pain has increased with her additional weight and postural changes. She reports that she had some back pain during and for a few months after her first pregnancy, but that, this time, it seems much worse. She has been trying to continue with a daily 20-minute walking program, but is finding that difficult because it increases the tension in her lower back region. On a 100mm Visual Analog Scale, she rates the pain in her lower back and pelvic region as varying from a constant 25mm to 50mm recently.
Exam Findings
Vitals. This gravid female has put on about 30 pounds in the past couple of months, and currently weighs 162 lbs, which, at 5’6’’, is within the expected range. She has never used tobacco, and stopped drinking alcohol as soon as she learned she was pregnant. She has had several pre-natal check-ups, and her blood pressure and pulse rate are within normal ranges. (BP—118/76 mmHg; pulse rate—68 bpm).
Posture and gait. Standing postural evaluation finds a hyperlordotic lumbar spine and a forward-tilted pelvis, which are associated with her enlarged abdomen. No lateral listing or curvature of her spine is seen, and her iliac crests and greater trochanters are level. She has a slightly widened stance, with moderate valgus alignment at the knees. There is also medial bowing of both Achilles tendons, with pes planus and hyperpronation bilaterally. During gait, both feet demonstrate an obvious toe-out (foot flare).
Chiropractic evaluation. Motion palpation identifies a very tender limitation in segmental motion at the left SI joint, and subluxations at L5/S1 and L2/L3. Kemp’s test provokes pain localized to the lower lumbar spine when performed to both sides, and reproduces the left hip and groin pain when done to the left. Spinal ranges of motion are otherwise normal and pain-free, and neurologic testing is negative for sensory, motor, and reflexive disorders.
Imaging. No radiographs were ordered, in consideration of her current pregnancy.
Clinical Impression
Chronic biomechanical strain of the lumbopelvic region is exacerbated by postural changes associated with the increased load of pregnancy. There is also poor support from the lower extremities, with excessive pronation interfering with her walking program.
Treatment Plan
Adjustments. Side posture adjustments were performed to the left sacroiliac joint and the lumbar spinal segments.
Support. She was fitted with custom-made, stabilizing orthotics based on foot imaging in mid-stance. The inserts were designed to provide support for her arches and decrease the biomechanical stress on her pelvis and sacroiliac joints during her pregnancy and after her delivery.
Rehabilitation. She was shown a standing posterior tilt exercise for the pelvis (pelvic extension) to activate and strengthen the abdominal support muscles and her transverse abdomens in particular. This exercise used the progressive resistance of elastic exercise tubing. She was also instructed to perform abdominal floor exercises (Kegels).
Response to Care
The adjustments were well tolerated, and resulted in immediate release of tension and rapid reduction in pain levels. She adapted easily to her orthotic inserts, and said that she noticed much greater stability in her feet and spine during walking. She performed her daily home exercise program regularly and with no strain or difficulty. She was treated weekly during the remainder of her pregnancy and then for six weeks after her delivery (a total of 12 visits). At that point, she was released to a self-directed maintenance program.
Discussion
The process of pregnancy, delivery, and post-partum places a great amount of structural stress on a woman’s body. In this case, poor support from the lower extremities increased the biomechanical strain, resulting in substantial distress. She responded well to the chiropractic adjustments, but she also needed the additional support from custom-made orthotics and professional guidance for specific postural exercises. (She delivered a healthy 7.2 lb. baby girl.)
Dr. John J. Danchik is the seventh inductee to the American Chiropractic Association Sports Hall of Fame. He is the current chairperson of the United States Olympic Committee’s Chiropractic Selection Program. He lectures extensively in the United States and abroad on current trends in sports chiropractic and rehabilitation. Dr. Danchik is an associate editor of the Journal of the Neuromusculoskeletal System. He has been in private practice in Massachusetts for 30 years. He can be reached by e-mail at [email protected].