Marie Mets

7/22/16

Will Core Stabilization Therapeutic Exercise Decrease

Low Back Pain During Pregnancy? A Randomized
Controlled Trial.
By: Marie Mets

Marie Mets
7/22/16
Date: 8/4/2016
Table of Contents
CHAPTER
I
INTRODUCTION
.... 3
Statement of Problems & Purpose of
Research... 5
II
REVIEW OF
LITERATURE. 6
Summary of Literature
Review.. 13
III
METHODS
14

Participants
14

Instrumentation
.. 14

Procedure
15

Analysis
16
IV
REFERENCES
. 17

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APPENDIX A: IRB
Approval
19
APPENDIX B: Informed Consent.
. 21
APPENDIX C: Data Collection
Form 22

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Will Core Stabilization Therapeutic Exercise Decrease

Low Back Pain During Pregnancy? A Randomized
Controlled Trial.
Marie Rene Mets, SPT

I. INTRODUCTION
It is common for women to experience low back pain (LBP) and pelvic
girdle pain (PGP) in the later stages of pregnancy 1. Pain is a major
reason why some women need to take maternity leave, or seek
medical attention during pregnancy1. Some womens pain can affect
their activities of daily living, their ability to walk long distances, drive
for longer periods of time, and stand pain- free while cooking. It is
known that some women exercise regularly before pregnancy in order
to maintain a healthy lifestyle when they are bearing a child. However,
exercising before pregnancy does not guarantee decreased pain in the
later stages1. It is very important that the mother continues to exercise
throughout her pregnancy in order to maintain her strength, balance,
and functional mobility. Most common forms of exercise for pregnant
women are yoga, walking, aquatics, and lightweight resistance
training. It is also common knowledge that women practice kegel

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exercises that focus on isometrically contracting the pelvic floor. All of
these exercises are great ways to stay active during pregnancy,
however they do not necessarily prevent low back pain. This may be
due to the fact that women gain a lot of extra weight that they are not
used to carrying around during the later stages of pregnancy. It is
possible that women are bearing this extra weight by putting additional
pressure onto their lumbar region. This, in time, could cause extra
stress on the low back, thus creating a painful and over-used area 2. To
decrease the amount of stress put onto the lower back, it is important
that pregnant women continue with kegel exercises to potentially allow
the pelvic floor to relieve the lower back of some of that stress.
However, kegel exercises alone may not help with a pregnant womans
functional movement. Women may need to learn how to contract their
pelvic floor, as well as their abdominal muscles to decrease stress load
on the lower back while they are performing different tasks. This
concept is called core stabilization.
Core stabilization exercises require simultaneous contraction of three
different muscles groups in the body: pelvic floor muscles, abdominal
muscles, and a varying group of muscles, depending on the exercise at
hand. The purpose of core stabilization is to utilize core and pelvic floor
muscles to balance the body while performing different tasks 3. For
example, a subject will contract their pelvic floor and transverse
abdominis muscles while performing bicep curls. Instead of putting

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extra strain on the subjects back during the exercise, the contraction
of the pelvis and core absorb that detrimental stress3.
If pregnant women learned more about core stabilization exercises and
the benefits of utilizing pelvic floor muscles to decrease stress on their
low back, pain could be decreased in that area. This study is meant to
compare a group of pregnant women who do not perform core
stabilization exercises and a group of pregnant women who do.
Comparisons will be made of their reports of low back pain and
functional abilities to determine if core stabilization exercises for
pregnant women are beneficial for decreasing pain and increasing
functional mobility during the later stages of pregnancy.
Statement of Problems & Purpose of Research
Problems
1. Will the use of core stabilization exercises decrease low back
pain during pregnancy?
2. Will exercise alone, without co- contraction of pelvic floor
muscles, decrease low back pain during pregnancy?
Statement of Purpose:

The purpose of this study is to determine

whether or not core stabilization therapeutic exercise will decrease low

back pain during pregnancy.
Perceived Limitations: In this study, it may be possible that there are
not enough participants to contribute to data collection. Another
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limitation to the study could be that participants were not further
categorized into weight classes because heavier women may have an
increased pain perception due to extra stress load on the body.
Researchers also did not look into overall physical fitness prior to
pregnancy and the mothers perceived pain tolerance prior to the
second trimester.

II. REVIEW OF LITERATURE

This research is analyzing the affects of core stabilization exercises
reducing low back pain in pregnant women. In order to fully understand
each component of the study, an extensive literary review has been
performed to gain more knowledge of pregnancy, pelvic floor
exercises, low back pain, and proper exercises for pregnant women.
These four topics will be addressed individually and in- depth to
understand the reasoning for the hypothesis: Pelvic floor and core
strength will help decrease pregnant womens low back pain. Appendix
A will also help explain why the specific population was chosen, and
discuss the importance of the exercises selected for this study.
Pregnancy: Pregnancy is a 9- month, 40 week, process that leads to
the birth of a child4. After conception, the process of birth is separated

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into three different trimesters to help mark the developmental
milestones during which fetal growth should occur. The first trimester
is 12 weeks long and it starts with microscopic changes that lead to
neural development of the spinal cord, brain, and organs 4. At the end
of gestational week 11, the baby will have formed a head, neck, eyes,
toes and genitals. It weighs approximately 8 grams at this point and
should be 2 inches in height (from the crown of their head to their
rump). At week 12, the baby grows fingernails, should now weigh 14
grams and measure as 2.5 inches tall from the crown of their head to
their rump5. The first trimester is the greatest risk period for
miscarriage. The second trimester lasts from Week 13- Week 27 and
mothers begin to notice an abdominal protrusion5. At week 14, the
babys sex becomes apparent and a heartbeat can be heard from
ultrasound5. At week 15, the fetus skeleton begins to take shape and
at week 17, fat begins to form for fetal protection and insulation 4. By
week 24, the baby is expected to be approximately 1.5 pounds and 8
inches long4. At week 26, the baby will be closer to 2 pounds and 9
inches in length5. It is important that participants in the current study
are in their second trimester because at this point, they have enough
baby weight in abdomen to affect a postural change and low back pain.
The third trimester encompasses weeks 29-40 and is the final stage of
fetal development before birth. At week 29, the babys bones are fully
developed and at week 30, they could measure at more than 10.5

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inches tall and be nearing 3 pounds in weight 5. Week 35 is the mark of
rapid weight gain for the fetus. At this point forward, the baby will be
moving around and taking up almost all of the available space in the
amniotic sac. Week 37 is considered to be early term, which means a
child could survive out of the womb, but many risks are involved with
this because the child has not fully developed yet. Some reasons why
children are born pre- maturely are due to stress, age of mother,
number of pregnancies prior, maternal smoking, and history of
miscarriages or pre- mature births prior to this pregnancy 6. If a child is
born pre- maturely, their nervous system may not have been fully
developed7. Pre- mature means a child is born less than 37 weeks
gestation and is less than 5 pounds in weight 7. This can cause risk of
post- partum neurodevelopmental abnormalities, behavioral problems,
decreased ability to adapt to change, and the child may struggle to
learn academically7. If the baby is not born early, then at week 40, the
child should be born. The baby should be approximately 18-20 inches
long and weigh at least 6.5 pounds. It is common for variations to
occur in height and weight of the child, depending on genetics and
maternal behaviors during the time of pregnancy 8. Mothers of the third
trimester were not selected to participate in the current study due to
the risk of having a pre-term birth. The study did not want to be
responsible for the abnormal development of a child due to potentially
over- stressing the mother during the later stages of pregnancy 8.

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Women were expected to be moderately active prior to pregnancy and
prior to the study to decrease the risks involved with pre- term birth.
No subjects were pushed past their limits during the research sessions
and each woman gave consent that she understood all potential risks
involved with the study, including pre- term birth or miscarriage and
that the research team would not be liable for these misfortunes.
Pregnancy and Exercise: In the past, there seemed to have been
controversy about whether or not women should exercise during
pregnancy because it could potentially put the fetus at risk of
hyperthermia9. Some practitioners encourage women to participate in
physical activity before pregnancy and then continue with that same
method of exercise during their pregnancy10. This is because the
mothers body will be adapted to this particular form of exercise
(whether its swimming, jogging, walking, or even yoga) and her body
will less likely overheat itself. It is also recommended that when a
mother is near the end of her second (and approaching her third)
trimester, she should consider more non- weight- bearing exercises
such as aquatic aerobics10. As the baby grows in the womb, the mother
has a lot of extra weight to carry in her abdomen that could potentially
lead to sore joints. Running with an increased amount of weight in the
abdomen can be detrimental to the mothers articular cartilage. Thus,
aquatic aerobics would be a sufficient way to stay in shape, keep the

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mothers joints healthy, and keep the mothers and babys core
temperature lower.
Aquatic therapy has been found to increase amniotic fluid diuresis and
decrease edema, blood pressure, and low back pain among pregnant
women9. Exercises can include stretching, walking back and forth,
swimming laps with a flotation device, and using underwater weights
for strengthening9. Pregnant women are encouraged to participate in
aquatic therapy for approximately 30-45 minutes per day. It has also
been found that healthy exercises during pregnancy can prevent
weight gain, pre- eclampsia, gestational diabetes, and depression 10.
Unfortunately, most women discontinue physical exercise as they
approach their second trimester10. A study was done in 2015 that
tracked 80 pregnant womens physical activity throughout pregnancy
using Fitbits. Fitbits are a wristband device that is worn to track the
amount of steps a person takes per day. The study found that the
participants categorized as obese walked significantly less steps per
day than the non- obese subjects. However, the study also found
that both the Obese and Non- obese subjects declined significantly in
the number of steps taken per day nearing the end of the third
trimester10. Other studies have demonstrated that only 23% of
pregnant women have reported healthy exercise habits during
pregnancy and that 1 in 3 pregnant women begin their pregnancy as
obese individuals11.

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Participating in a pregnancy support group or group exercise class for
pregnant women may increase the likelihood of women participating in
physical activity during the later stages of pregnancy. A study done in
2012 gathered a group of 257 pregnant women between the ages of
18-40 years and before 20 weeks of gestation 11. The aim of the study
was to determine whether group exercise and ergonomic advice could
decrease prevalence of low back pain (LBP) and pelvic girdle pain
(PGP) among pregnant women. The results to the study indicated that
women did not report any decrease in LBP or PGP pain due to the
group exercise program. The studys exercise sessions were for 60
minutes and only once per week. However, despite the poor outcome
of pain relief, these women were still exercising until week 36 of
gestation, which as stated earlier, is uncommon and can still increase
overall health benefits for the mother and her baby.
The social aspect of group exercise could potentially be enough to keep
women engaged in exercise during the later stages of pregnancy 11.
Participating in a group fitness class with women who are experiencing
similar

symptoms

or

discomfort,

may

promote

supportive

atmosphere. This could possibly encourage the women to feel that

they are working together to create a healthy future for their child11. No
research has been found to acknowledge whether group exercise
classes can increase a pregnant womens motivation to exercise during
the later stages of pregnancy11.

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Low Back Pain:

Low back pain is a very broad topic with many

potential causing factors. Some underlying influences leading to low

back pain could be sacroiliac joint misalignment, lumbovertebral
misalignment, knee or ankle misalignment, poor posture, excessive
weight bearing, hormonal imbalances causing ligaments to be looser,
or psychosocial stressors. In regards to pregnant women, most of these
potential problems listed could be problems for low back pain. The two
most common causes for low back pain during pregnancy might be
excessive weight bearing and poor posture of the mother. During
pregnancy, women increase their body weight by 15-25%, which
causes increased lordodic curve to the lumbar spine 12. There is also a
considerable increase in kyphosis of the thoracic curve due to
increased breast tissue and compensation for the lordosis of the
lumbar spine12. Due to the abnormal increase in spinal curvature, the
erector spinae muscles have to compensate in order to keep the body
balanced and stable12. The erector spinae attach onto the vertebrae of
the spine, thus overstressing these muscles leads to pulling on the
spine itself. When a muscle is pulling on the vertebrae more than it is
meant to, back pain can arise as a symptom. To relieve their LBP or
PGP,

some

women

utilize

support

belt

during

pregnancy.

Unfortunately, there is not an ample amount of scientific evidence

supporting the validity of these belts 13. A typical elastic support belt
wraps around the waist and underneath the belly to help support the

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weight of the fetus. A study in 2008 was done to evaluate the different
types of support belts and identify which was more effective for pain
relief of a pregnant woman13. The study was inconclusive in that most
of the belts did not substantially relieve pain at all. The study advised
readers to wear the belts and begin a personal exercise program
catering to the pregnant mothers needs. The study determined that
these belts would not relieve pain to sedentary mothers13.
Pain can be perceived in many ways and can be classified by use
of different tools or scales. The Oswestry Low Back Pain Disability
Questionnaire was used for this current study to determine each
participants functional status in regards to their low back pain. Other
scales that can be used to determine a subjects pain and functional
mobility are: the Quebec Back Pain Disability Scale, The Roland Morris
Disability Questionnaire, and the Waddell Disability Index 14.

Physical

Therapists are encouraged by Insurance companies to use recognized

back pain indexes in order to reimburse their clients medical bills.
Insurance companies need valid functional indices for proof their that
clients are truly in need of medical care. The problem with pain scales
is that full trust is given to the subjects to answer these questionnaires
as honestly as possible. People sometimes stretch the truth and
perceive their pain problem to be more detrimental than it truly is. In
previous clinical experience, patients lie or misperceive their pain for
sympathy, to receive workers compensation, to file for unemployment,

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or to continue receiving medication from their primary physicians. A
study examined pregnant women catastrophizing their symptoms 2.
Catastrophizing is having an over-exaggerated reaction to a stimulus
that normally would not cause such hyperstimulation. In regards to
pregnant women, those who catastrophize about labor tend to report
higher pain during labor than the women who did not catastrophize 2.
Post- partum depression is also a risk factor for women who
catastrophize before birth. These are all things that reserachers and
therapists need to keep in mind during treatment sessions. Physical
therapists should always document the catastrophizing being said in
the clinic in regards to their pregnant patients. This may help other
therapists later, who may see that patient for different issues, and help
them understand that this patient tends to have a lower pain tolerance
than most. For researchers, it is important to look out for these types of
subjects and reason with their perception of their pain levels before
entering the study. Over-exaggerated questionnaires could most
certainly skew the data collection.
Summary of Literature Review
Women in their 2nd and 3rd trimesters of pregnancy commonly fail to
achieve the daily- recommended volume of exercise each day
(approximately 30 to 45 minutes). A common reason for this decline in
physical activity is due to the extra weight- bearing load a pregnant

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mother carries. The weight of the growing fetus can increase the stress
put on a mothers joints, causing pain and soreness with functional
activities. Some women perceive pain differently than others and
anticipate more pain in certain situations. For example, some women
may fear childbirth and fear that it will be a traumatic experience.
These women tend to report higher pain during childbirth, than
compared to woman who do not fear the process and did not assume
that it would be unbearable pain. As researchers, it is important to
keep this knowledge in mind while working to find low back pain status
in pregnant women. Most of the study relies on Low Back Pain
questionnaires to determine the results of core stabilization exercises.
This means that the participants are fully entrusted into giving an
honest measurement of their low back pain, and do not perceive their
pain to be higher than what it truly is. Researchers will take this
knowledge and apply it to the studys protocol in order to ensure safe,
appropriate exercises for the participants and to further understand
the participants different perceptions of pain.

III. METHODS
Participants: Pregnant women were recruited between 3 and 6 months
gestation, who currently presented with low back pain. Women were
excluded from the study if they had pre- natal severe low back pain, or

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previously existing conditions that would hinder their ability to exercise
and maintain full functional mobility. Only women bearing 1 child were
allowed to participate in the study. Women of every age and race were
permitted to participate. Participants agreed to strictly follow the
research protocol in regards to therapeutic exercise and to discontinue
any extra physical activity outside of the research setting that was not
approved by the researchers.
Instrumentation: The Oswestry Low Back Pain Disability Questionnaire
(OLBPDQ) was used as a pre and post- study system to measure the
improvements of each subject. The OLBPDQ is a survey determining
the functional abilities and disabilities of a patient with low back pain.
There are 10 questions total, each with 5 possible answers. The top
answer is considered 0 points, and the bottom answer is considered 5
points, thus 50 total points can be earned. If a question is nonapplicable to the patient, then that question will simply be voided and
the new score would be calculated without the voided questions being
included. The ten questions are titled as: pain intensity, personal care,
lifting, walking, sitting, standing, sleeping, sex life, social life, and
traveling. The first box under each category says that the patient has
no pain with this activity. The last box under each category says that
excruciating pain comes with this activity, thus its virtually impossible
for them to achieve. The doctor will add up the scores at the end and
divide them by 50 (or however many points were applicable to that

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subject) and then multiply it by 100. The test score indications are as
follows: 0-20% minimal disability, 21-40% moderate disability, 41-60%
severe disability, 61-80% handicapped, and 81-100% bed- bound or
exaggerating symptoms.
Procedure: In the state of Michigan, all gynecologists were informed of
the study and encouraged to inform their pregnant patients of the
study. An e- mail address was given to each gynecologist for
communication with the researchers and the participants. Flyers were
also put in all hospital waiting rooms in which the gynecologists
worked. Of the qualifying participants who contacted the research
facility, 18 names were drawn out of a hat to determine the official
participants. The 18 women selected for this study were randomly
divided into two groups, with 9 subjects in each group: A) the control
group and B) the core stabilization strengthening group. Participants
were not told that this study was examining core stabilization exercises
to reduce low back pain. Instead, subjects were told that this study was
examining low back pain and the affects of therapeutic exercise in
general. All women were asked to participate in research 3 times per
week for 45 minutes each, for 2 months; a total of 12 therapeutic
sessions. All exercise sessions were performed in a physical therapy
setting, lead by the researchers. Exercises included standing ham
curls,

standing

marches,

standing

hip

extension,

standing

hip

abduction, therapy ball core stabilization exercises, supine bridges, and

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side- lying clams. Subjects were given a take- home exercise plan of
these include exercises to perform once per day on days they do not
need to attend a therapy session. Women were asked each visit if they
have been participating in their home exercise plan to monitor
compliance. No subjects gave birth during this study, and none were
forced to drop- out to due non- compliance with the fitness program.
Both Groups A and B took a Pre and Post OLBPDQ as a means of
functional measurements. Group B was given core stabilization and
pelvic floor exercises to decrease their low back pain. Group A was
given basic full-body strengthening that mimicked group Bs exercises,
only without contraction of the core and pelvic floor during the
exercises. Both groups were given a home exercise plan that was to be
done once on each day they did not have to come in for research.
Analysis:

Each patients before and after scores from the OLBPDQ

were calculated and converted it into a percentage: (after/ before) X

100 to determine a percentage of improvement. A plot graph was used
to record each score. Group As results are dotted in Red and Group Bs
results are dotted in Blue. This will help clearly identify if the
improvement of Group B was higher than Group A. This would
determine if core stabilization exercises simultaneously with regular
therapeutic exercise is a better way to decrease low back pain during
pregnancy, compared to just therapeutic exercise. Using a computer

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program, the data will be statistically analyzed to assure that the
findings are significant.

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IV. REFERENCES
1. Eggen MH, Stuge B, Mowinckel P, Jensen KS, Hagen KB. Can
supervised group exercises including ergonomic advice reduce
the prevalence and severity of low back pain and pelvic girdle
pain in pregnancy? A randomized Controlled Trial. Physical Ther.
2012; 92: 781-790.
2. Olsson CB, Grooten WJA, Nilsson- Wikmar L, Harms- Ringdahl K,
Lundberg M. Catastrophizing during and after pregnancy:
associations with lumbopelvic pain and postpartum physical
ability. Physical Ther. 2012; 92: 49-57.
3. Koumantakis GA, Watson PJ, Oldham JA. Trunk muscle
stabilization training plus general exercise versus general
exercise only:
randomized controlled trial of patients with
recurrent low back pain. Physical Ther. 2005; 85: 209-225.
4. Pregnancy: Stages of pregnancy. U.S. Department of health and
Human Services. http://www.womenshealth.gov/pregnancy/youare-pregnant/stages-of-pregnancy.html. Accessed July 16, 2016.
5. Healthy Lifestyle: Pregnancy week by week.
http://www.mayoclinic.org/healthy-lifestyle/pregnancy-week-byweek/in-depth/prenatal-care/art-20045302. Accessed July 16,
2016.
6. Sekizula- Kagami, N, Shimada K, Tabuchi, N, Nakamura, H.
Association between the sense of coherence 13- item version
scale score of pregnant women in second trimester of pregnancy
and threatened premature birth. Environ Health Prev Med. 2015;
20: 90-96.
7. Di Rosa G, Cavallaro T, Alibrandi, A, Marseglia L, Lamberti M,
Giaimo E, Nicotera A, Bonsignore M, Gagliano A. Predictive role of
early milestones- related psychomotor profiles and long- term
neurodevelopmental pitfalls in preterm infants. Early Human Dev.
2016; 101:49-55.
8. Gaillard R, Steegers E AP, Jongste J, Hofman A, Jaddoe V. Tracking
of fetal growth characteristics during different trimesters and the
risks of adverse birth outcomes. International Journal of
Epidemiology. 2014; 43:1140- 1153.
9. Da Silva et al; Effects of an aquatic physical exercise program on
glycemic control and perinatal outcomes of gestational diabetes:
study protocol for a randomized controlled trial. Trials 2013.
14:390.
10.
Huberty JL, Buman MP, Leiferman JA, et al. Trajectories of
objectively- measured physical activity and sedentary time over
the course of pregnancy in women self- identified as inactive.
Preventive Medicine Reports. 2016;3: 353-360.

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11.
Tinius RA, Cahill AG, Cade WT. Origins in the womb:
potential role of the physical therapist in modulating the
deleterious effects of obesity on maternal and offspring health
through movement promotion and prescription during pregnancy.
Phys Ther. 2016;96:1-27
12.
Schroder G, Kundt G, Otte M, et al. Impact of pregnancy on
back pain and body posture in women. J. Phys. Ther. Sci. 2016;
28: 1199-1207.
13.
Ho S SM, Yi W WM, Lao TT, et al. Effectiveness of maternity
support belts in reducing low back pain during pregnancy: a
review. Journal of Clinical Nursing. 2009; 18: 1523-1532.
14.
Davidson M, Keating JL. A comparison of five low back
disability questionnaires: reliability and responsiveness. Phys
Ther. 2002;82:4-24.

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