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Evaluation of the efficacy of an exercise program for pregnant women with

low back and pelvic pain: A prospective randomized controlled trial

Article  in  Journal of Advanced Nursing · March 2015

DOI: 10.1111/jan.12659

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ORIGINAL RESEARCH: CLINICAL TRIAL
Evaluation of the efficacy of an exercise program for pregnant women
with low back and pelvic pain: a prospective randomized controlled
trial
Serpil Ozdemir, Hatice Bebis, Tulay Ortabag & Cengizhan Acikel
Accepted for publication 18 February 2015
Correspondence to S. Ozdemir:
e-mail: serpilozdemir327@gmail.com
Serpil Ozdemir PhD RN
Lecturer
Public Health Nursing Department, School
of Nursing, Gulhane Military Medical
Academy, Ankara, Turkey
Hatice Bebis PhD RN
Assistant Professor
Public Health Nursing Department, School
of Nursing, Gulhane Military Medical
Academy, Ankara, Turkey
Tulay Ortabag PhD RN
Associate Professor
Public Health Nursing Department, School
of Nursing, Hasan Kalyoncu University,
Sahinbey, Gaziantep, Turkey
Cengizhan Acikel MD
Associate Professor
Public Health and Epidemiology
Department, Gulhane Military Medical
Academy, Ankara, Turkey
© 2015 John Wiley & Sons Ltd
O Z D E M I R S . , B E B I S H . , O R T A B A G T . & A C I K E L C . ( 2 0 1 5 ) Evaluation of the
efficacy of an exercise program for pregnant women with low back and pelvic
pain: a prospective randomized controlled trial. Journal of Advanced Nursing 00
(0), 000–000. doi: 10
1111/jan.12659
Abstract
Aim. To evaluate the effect of exercise programs on pregnant women with
pregnancy-related low back and pelvic pain.
Background. Low back and pelvic pain during pregnancy is a major health
problem due to its frequent occurrence and such pain can limit pregnant women
in many of their daily activities.
Design. A randomized trial with a control group (n = 48) and an intervention
group (n = 48). Trial registration number NCT02189356.
Methods. Department of Obstetrics and Gynecology, between December 2011–
May 2012, an Education and Research Hospital in Turkey. Based on the
intention-to-treat principle, all pregnant women were analysed according to the
group they were assigned to, regardless of whether they received the intervention
or not. Participants in the intervention group received health counselling and
exercised regarding low back and pelvic pain for four weeks. The pregnant
women in the control group received usual care, comprised of routine clinical
practice for pregnancy-related low back and pelvic pain.
Results. According to Mann–Whitney U test analysis results, there was a
statistically significant difference between the control and intervention groups’
Visual Analogue Scale during relaxation scores and Visual Analogue Scale during
activity scores at the end of the study. According to Mann–Whitney U test
analysis results, the change in the mean Oswestry Disability Index score for the
intervention group and the difference in the mean scores between the two groups
was statistically significant.
Conclusions. A four-week exercise program including individualized health
counselling to relieve low back and pelvic pain improved the functional status in
pregnant women.
Keywords: pregnancy-related low back and pelvic pain, exercise program, nurse
1
S. Ozdemir et al.
Why is this research or review needed?
 Previous studies have reported that one quarter of women
with low back and pelvic pain during pregnancy had
severe pain.
 In previous studies, 8-36% of women with low back and
pelvic pain during pregnancy had various degrees of func-
tional impairment.
 Although some studies have reported that exercise pro-
grams are effective for pregnancy-related low back and pel-
vic pain, there were also studies with conflicting findings.
What are the key findings?
 Although this study was conducted in a small sample, reg-
ular exercises during pregnancy may substantially relieves
or resolves pregnancy-related low back and pelvic pain.
 Regular exercises during pregnancy may promote
improved functional status.
How should the findings be used to influence policy/
practice/research/education?
 Pregnant women could always be asked about low back
and pelvic pain at prenatal clinic visits.
 Services that include preventive approaches to low back
and pelvic pain could be provided to pregnant women
with pregnancy-related low back and/or pelvic pain and
regular exercise programs should be implemented.
Introduction
Every woman has the right to a healthy pregnancy (Tasßkın
2007). Some health problems that arise due to the natural
course of pregnancy may negatively affect maternal and
foetal health (Mogren 2000, Pennick & Young 2007, Pen-
nick & Liddle 2013). Low back and pelvic pain (LBPP) is
one of the most frequently reported disorders in pregnancy
all over the world (Mogren 2000, Pennick & Young 2007,
Elden et al. 2008, Chang et al. 2011, Pennick & Liddle
2013), beginning during pregnancy and continuing until the
postpartum period. Also LBPP is not necessarily unhealthy
symptom– it is a symptom that is common in healthy preg-
nancies (Tasßkın 2007, Verstraete et al. 2013). LBPP may
recur during subsequent pregnancies and have lifelong
effects (Damen et al. 2001, R€ost et al. 2006, Chang et al.
2011, 2012). Previous studies have reported that between
20% and 90% of women experience LBPP during preg-
nancy (Perkins et al. 1998, To & Wong 2003, Albert et al.
2006, Mazicioglu et al. 2006, Robinson et al. 2006, Kalus
et al. 2008, Ji & Ha 2010, Vermani et al. 2010, Bjelland
et al. 2011), making LBPP in pregnancy a major women’s
2 © 2015 John Wiley & Sons Ltd
health and public health issue (Wang et al. 2004, Bastiaans-
sen et al. 2005a,b, Mogren & Pohjanen 2005).
There is evidence that the physiological changes of preg-
nancy cause LBPP and that LBPP adversely affects pregnant
women’s health and their biological, psychological, social
and economic well-being. (Stapleton et al. 2002, Nilsson-
Wikmar et al. 2005, Sabino & Grauner 2008). Women
with LBPP during pregnancy have difficulties in walking,
sleeping and many of the activities of daily living (Wang
et al. 2004, Nacır et al. 2009, Vermani et al. 2010). As the
pregnancy progresses, the pain tends to increase in severity.
Aggravation of the pain may lead to severe functional dis-
ability and a decreasing quality of life for pregnant women
(Bj€
orklund et al. 1999, Olsson & Nilsson-Wikmar 2004,
Bjelland et al. 2011). Previous studies have reported that
25% of women with LBPP during pregnancy had severe
pain and that 8-36% of had some degree of functional dis-
ability (Stapleton et al. 2002, Gutke et al. 2006, Pennick &
Young 2007, Kalus et al. 2008, Gutke et al. 2008, Bjelland
et al. 2011, Saccomanni 2011, Chang et al. 2012, Pennick
& Liddle 2013). For 10% of pregnant women with LBPP,
their pain prevents continuing their work. (Stapleton et al.
2002, Sabino & Grauner 2008). The literature shows that
LBPP- related work absences are a huge burden on the
country’s economy and on individuals’ budgets (Carr
2003, Olsson & Nilsson-Wikmar 2004, Sabino & Grauner
2008).
Prevention, early diagnosis and treatment of pregnancy-
related LBPP may protect, maintain and improve the health
of pregnant women, positively affecting both the health of
individuals and public health.
Background
Although pregnancy-related LBPP is a major women’s
health problem, options for pain management remain lim-
ited due to the potential harm to the foetus (Perkins et al.
1998, Kanakaris et al. 2011, Saccomanni 2011). Further
obstacles to the proper prevention, diagnosis and treatment
of LBPP include a lack of knowledge of current treatment
options and the assumption that pain is ‘a natural conse-
quence of pregnancy’ by both pregnant women and clini-
cians (Vermani et al. 2010, Kanakaris et al. 2011). It has
been reported that only 32% of the pregnant women with
LBPP mentioned their pain to a healthcare professional and
that 75% of healthcare professionals did not use any treat-
ment method to manage the pain (Wang et al. 2004). How-
ever, there is evidence that pregnant women desire
information from healthcare professionals regarding the
prevention and reduction in LBPP during the prenatal clinic
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Pregnancy-related low back and pelvic pain

visits (Greenwood & Stainton 2001). Nurses who provide Design

basic health care during prenatal clinic visits play an impor-
The study was a prospective randomized trial with a con-
tant role in the prevention and treatment of LBPP and in
trol group (standard care group) and an intervention group,
meeting the expectations of their patients (Shima et al.
using a repeated measures design, trial registration number
2007).
NCT02189356. 48 pregnant participants with pregnancy-
Reports from the literature characterize pregnancy-related
related LBPP were included in the control group and 48
LBPP as a preventable and treatable health problem (Reeder
pregnant participants with pregnancy-related LBPP were
et al. 1997, Pillitteri 2007). Professional nurses may protect
included in the intervention (exercise) group.
women’s health during pregnancy by effectively managing
LBPP using evidence-based practices (Shima et al. 2007).
Methods for the management of LBPP include regular Participants
exercise programs, health education, acupuncture, rest,
This research was performed between December 2011–May
pharmacological options, Transcutaneous Electrical Nerve
2012 at the Department of Obstetrics and Gynecology,
Stimulation (TENS), the use of specially shaped pillows,
Gulhane Military Medical Education and Research Hospital
sacroiliac belts and pregnancy corsets, the application of
in Ankara, Turkey. Approximately 3000 births occur annu-
heat and/or cold and various complementary medicine
ally at this clinic. Participants were pregnant women who
options (Stuge et al. 2003, Mens et al. 2006, Pennick &
presented to the obstetrics department for routine pregnancy
Young 2007, Pennick & Liddle 2013).
examinations, had pregnancy-related LBPP and fulfilled the
There is evidence that the use of exercise programs before
eligibility criteria. 209 pregnant women were evaluated
and during pregnancy can provide effective pain manage-
between the indicated dates. Forty three women did not
ment for women with LBPP, although some studies
meet eligibility criteria, 54 pregnant women refused to par-
reported conflicting findings (Ostgaard et al. 1994, Nilsson-
ticipate in the study and 16 pregnant women were excluded
Wikmar et al. 2005, Shima et al. 2007, Gutke et al. 2008,
from the study because of other reasons such as moving to
Dumas et al. 2010). Past systematic reviews of randomized
another city, not completing the forms regularly. Ninety-six
controlled trials examining this issue have cited many limi-
pregnant women who met the eligibility criteria accepted to
tations to the available research, including the types of
participate in the study and were randomized (Figure 1 Flow
research, the methods, the sample sizes and the significant
chart). Eligibility criteria of the research were determined
potential for bias (Stuge et al. 2003, Pennick & Young
following a literature review (Stuge et al. 2003, Sabino &
2007, Mens et al. 2009, Vermani et al. 2010, Kanakaris
Grauner 2008, Mens et al. 2009, Robinson et al. 2010,
et al. 2011, Pennick & Liddle 2013).
Chang et al. 2012). The eligibility criteria were:
Therefore, we determined a need for a well-designed,
prospective, randomized controlled study with an adequate • Age over 18 years old
sample size and power. The research should demonstrate • Ability to read and write in Turkish,
the effectiveness of exercise programs to relieve and/or • Volunteering to participate in the study,
resolve pregnancy-related LBPP. In this context, this study • Being between 20-35 weeks of gestation,
primarily aimed to demonstrate if exercise programs can • Having no complications for any reason during the study,
increase functional capacity and effectively relieve preg- • No diagnosis of low back and/or pelvic disease prior to
nancy-related LBPP. pregnancy,
• Not performing exercise for half an hour at least
3 days a week during pregnancy,
The study
• Not using analgesics for low back and pelvic pain,

Aim
The aim of this study was to evaluate the effect of exercise
programs on pregnant women with pregnancy-related
LBPP. Hypotheses of the study were: (1) Exercise programs
relieve the intensity of LBPP in pregnant women; and (2)
Exercise programs promote functional capacity for pregnant
women with LBPP.
• Not using other methods for the treatment low back
and pelvic pain.
Interventions
Participants diagnosed with pregnancy-related LBPP by a
doctor and with no medical obstacles to participation in
the study were directed to nurse. The nurse invited the

© 2015 John Wiley & Sons Ltd 3

S. Ozdemir et al.

Enrollment Assessed for eligibility (N = 209)

Excluded (n = 113)
Declined to participate (n = 54)

Pregnant women with pregnancy-related LBPP (N = 96) Not meeting eligibility criteria (n = 43)

First meeting Other reasons (no time or no interest) (n = 16)

- Collecting dates about the characteristics of the pregnant woman

- Assessment of low back and pelvic pain
- Determination of functional level

Randomized (N = 96)

Allocation Intervention GroupI (n = 48)

Control Group (n = 48)
− Usual care − Usual Care
− Applying information training of low back and pelvic pain and giving education
− Explanation of how to fill the pain
booklets
follow-up forms weekly and − Applying protection methods education of low back and pelvic pain and giving
distribution of the forms education booklets
− Applying exercise training, giving exercise diary and education booklet
− Explanation of how to fill the pain follow-up forms weekly and distribution of the
forms

First week: three telephone calls (n = 48)

First week: one telephone call (n = 48) − Application of the exercise program
− Keeping a diary of exercise
− Following up the pain weekly F − Following up the pain weekly
O
L
Second week: one telephone call (n = 48) L Second week: three telephone calls (n = 48)
O
− Following up the pain weekly W − Application of the exercise program
− Keeping a diary of exercise
U − Following up the pain weekly
P
Third week: one telephone call (n = 48)

− Following up the pain weekly Third week: three telephone calls (n = 48)

− Application of the exercise program

− Keeping a diary of exercise
Fourth week: one telephone call (n = 48) − Following up the pain weekly

− Following up the pain weekly

Fourth week: three telephone calls (n = 48)

− Application of the exercise program

− Keeping a diary of exercise
− Following up the pain weekly

Face to face interview at the end of the fourth week (n = 96)

- Collecting dates about the characteristics of the pregnant woman

- Assessment of low back and pelvic pain
- Determination of functional level
- Analysis of the data obtained and the assessment of results Analyses

Figure 1 Flow chart.

4 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: CLINICAL TRIAL
pregnant women to the research room for a discussion on
low back and pelvic pain. After the eligibility criteria of the
pregnant women were reviewed, initial assessments were
completed and the participants were subsequently random-
ized (Figure 1).
The nurse gave health counselling to the participants in
the intervention group about the prevention of pregnancy-
related LBPP and initiated an exercise program that
included exercise training. The health counselling and exer-
cise training booklets provided were prepared based on the
literature (Wang et al. 2004, Pillitteri 2007, Akbayrak &
Kaya 2008, Vermani et al. 2010). Each counselling session
lasted an average of 45 minutes. Sessions were completed
in a positive education atmosphere and were face-to-face as
consistent with the principles of adult education (Sullivan
et al. 1999). The structure and function of the vertebrae,
physical changes occurring during pregnancy, causes of
pregnancy-related LBPP, the problems that the pain causes,
methods of pain management, correct posture development,
body mechanics during activities of daily life and ergonom-
ics were explained to the pregnant women using illustrated
booklets given during the trainings. During the counselling,
the nurse received information from the participants about
their daily activities and educated the participants about the
behaviours that might damage the low back and pelvic
regions. Participants were given practical demonstrations of
how to move and how to protect the low back and pelvic
regions during daily life. For example, the nurse demon-
strated how to retrieve an object from the ground, how to
reach shelves, how to sit and stand up and how to lie
down, guiding the participants through these activities as
well. The participants’ questions were answered and they
were given educational booklets. Following the health con-
sultation, exercise education was given. The participants
were given illustrated booklets explaining the effects of
pregnancy exercises on maternal and foetal health, situa-
tions that need attention before starting and during exer-
cises, signs of danger, what should be done in potentially
dangerous situations, how to breathe during exercise and
the method, frequency and amount of the exercise. The
exercises given to the intervention group were based on the
guidelines from ‘Exercise in Pregnancy’ by the Royal Col-
lege of Obstetricians and Gynaecologists (RCOG) and the
guidelines from ‘Pregnancy and Exercise’ by Hacettepe Uni-
versity in Turkey (Reeder et al. 1997, Pillitteri 2007, Ak-
bayrak & Kaya 2008). It was emphasized that pregnant
women should complete their exercises as shown at least
3 days a week for 30 minutes (Reeder et al. 1997, Pillitteri
2007, Akbayrak & Kaya 2008). The duration of the exer-
cise program was 4 weeks. Participants were offered a
© 2015 John Wiley & Sons Ltd
Pregnancy-related low back and pelvic pain
choice of two types of exercise according to the weather
conditions. The first option comprised exercises performed
on a mattress, including stretching, tightening and loosening
movements that targeted large muscle groups from the neck
to the vertebrae. The nurse explained that the mattress
exercises would start with a 5 minute warm up, continue
for at least 15-20 minutes at mid-tempo and end with a
5 minute cool down. The second option was a walking
exercise. The participants were expected to warm up for
5 minutes, increase their speed for 5 minutes, continue at
mid-tempo for 15 minutes and complete a 5 minute cool
down. It was emphasized that the pulse rate should be
between 120-160/min when the participants reached mid-
tempo. In this exercise program, we assumed that both the
walking exercise and the mattress exercises had equal
effects on the low back and pelvic pain. Pregnant women
were able to choose the type of exercise according to their
wishes and requirements and could use either or both of
the exercise options. The nurse determined the exercise plan
with the pregnant women, creating an individual exercise
program according to the patient’s personal characteristics.
The participants were asked to record the type and the
duration of the completed exercises during the program on
the data collection form and were asked to note if they
encountered any problems during the program. The nurse
taught the participants how to complete the forms and
answered any questions about the programs. The nurse
spoke with the pregnant women on the phone three times a
week and gave counselling according to their needs. During
interviews, pregnant women were reminded to complete the
data collection forms. After 4 weeks, the researchers made
a final assessment of the pregnant women and collected the
forms during a face-to-face interview. The exercise pro-
grams were terminated at this point, though (Figure 1) the
pregnant women were able to continue the counselling if
they wished. At the end of the study, pregnant women in
the intervention group were asked to note if they meet any
side effects of the exercise. There was not any negative
feed-back about the exercise program.
The pregnant women in the control group received usual
care, comprised of routine clinical practice for pregnancy-
related LBPP. Usual care is comprised of movement without
straining herself in daily life, often forcing herself to rest,
taking paracetamol pills and consultation physical therapy
clinic for LBPP. In the study, the doctor did not find it nec-
essary for the control group participants to be consulted to
physical therapy clinic. None of the pregnant women in the
control group used paracetamol pills because they were
afraid of side effects on their baby. Nurse did not tell the
control group participants about not to exercise. If they
5
S. Ozdemir et al.
wanted to exercise they would do, there were no obstacle
for doing exercise.
The nurse spoke with the women in the control group on
the phone once a week and asked them to assess their LBPP
and complete the data collection form. The final assess-
ments of the participants were made during a face-to-face
interview 4 weeks later (Figure 1). In the last assessment,
nurse asked to the control group participants ‘do you exer-
cise three times a week at least half an hour regularly?’ and
‘do you know anything about exercises for LBPP’. At the
end of the study, the control group participants said that
they did not exercise and they did not know the exercise
for LBPP. Willing pregnant women in the control group
were advised on pain management strategies such as exer-
cise program after completion of the 4 weeks of the study.
Sample size and statistical power considerations
The sample size was calculated using the PS Software: Power
and Sample Size program (http://biostat.mc.vanderbilt.edu/
wiki/Main/PowerSampleSize). Using the literature, we calcu-
lated that a sample size of 48 pregnant women in both the
exercise group and the control group (total 96 pregnant
women) could allow for detection of a difference in VAS
score of 10 mm between the intervention and control group,
given a SD of 15 mm with accompanying 0
95% confidence
intervals (CI) and a power of 0
90 (Kalus et al. 2008). Ten
mm difference in VAS score between the intervention and
control group was accepted as meaningful based on Kalus
et al.’s (2008) study and our clinic obstetrician experience.
Randomization
According to the CONSORT requirements, the participants
were randomly allocated to either the intervention group
(n = 48) or the control group (n = 48) using opaque, sealed
envelopes and a simple randomization method. The clinic
nurse who was independent from the study, at the clinic
randomly drew the envelopes and broke the seal in the
nursing room (Kanık et al. 2011). After the randomisation,
No hurt
Figure 2 Visual analog scale.
6 © 2015 John Wiley & Sons Ltd
the research nurse explained the study’s purpose and proce-
dures to the pregnant women in the control and interven-
tion groups. The same procedure was repeated for all the
pregnant women. Blinding of participants was not feasible
due to the study design.
Primary outcomes
The primary outcomes of this study were the change in
pain intensity at the end of 4 weeks compared with the
baseline and the changes in functional status at the end of
weeks first and fourth.
Data collection
The nurse collected the data by meeting with the pregnant
women at the beginning and end of the study for a total of
two interviews. The data collection form included the soci-
odemographic characteristics of the pregnant women, their
pregnancy history and questions about any history of pain.
In these meetings the nurse measured the severity of the LBPP
and determined the functional status of the pregnant women.
The participants measured the severity of LBPP at the end of
each week for a total of 4 measurements and recorded their
pain on a ‘Weekly Pain Follow-up Form’. Additionally, par-
ticipants in the intervention group recorded their exercises
on a ‘Daily Exercise Form’. The forms were collected for
evaluation by the nurse at the completion of the study.
Measures
Validity and reliability of pain intensity
We used the Visual Analogue Scale (VAS) to measure the
intensity of the participants’ pain. The VAS is a reliable
and valid scale that widely used all over the world for the
assessment of pain intensity (Wewers & Lowe 1990, Linds-
eth & Vari 2005, Kalus et al. 2008, Murphy et al. 2009,
Potter et al. 2013). Pregnant women noted the severity of
the low back and pelvic pain that they perceived on a
100 mm VAS (Figure 2). The nurse determined the intensity
Hurts worst
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL
of pain by measuring the point the pregnant woman had
marked with a ruler. We examined the intensity of two
types of pain; perceived pain intensity at rest as VASrelaxation
and perceived pain intensity during activity as VASactivity.
Validity and reliability of functional level
The Oswestry Disability Index (ODI) was used to determine
the participants’ functional status. The ODI was developed
in 1976 by O’Brien (Fairbank & Pynsent 2000) and is a
condition-specific outcome measure used in the manage-
ment of spinal disorders. The ODI has been broadly tested
and was found to have good psychometric properties and
to be useful in a wide variety of settings (Fairbank & Pyn-
sent 2000). The ODI is the ‘gold standard’ for low back
functional outcome instruments (Fairbank & Pynsent
2000), is self-administered and consists of a 10-item ques-
tionnaire. The first section evaluates the intensity of pain
and the others describe its disabling effects on typical daily
activities including personal care activities (washing, dress-
ing), lifting, walking, sitting, standing, sleeping, social life
and travelling. Each item is scored from 0-5, with higher
values demonstrating greater disability (Fairbank & Pynsent
2000). The ODI’s validity and reliability in the Turkish
population was examined by Yakut et al. (2004) and the
Cronbach a value was reported as 0
91 (Yakut et al. 2004).
Exercise level
Exercise diaries are easy, cost-effective and frequently used
methods to measure physical activity (Lindseth & Vari
2005). In this study, exercise diaries were used to determine
the exercise levels of participants in the intervention group.
Exercise for 30 minutes at least 3 days a week was consid-
ered sufficient.
Ethical considerations
An Academy Ethical Committee approved the study design,
protocols and informed consent procedure with number
1491-348-11/1539-227. Participants were informed about
the study before inclusion and could decline to participate
at any time. The participants read and signed the informed
consent form with the help of the nurse at the beginning of
the study.
Data analysis
Based on the intention-to-treat principle, all pregnant
women were analysed according to the group they were
assigned to, regardless of whether they received the inter-
vention or not. To investigate the differences between the
© 2015 John Wiley & Sons Ltd
Pregnancy-related low back and pelvic pain
groups, the Student’s t-test was used for values with a nor-
mal distribution and the Mann–Whitney U-test was used
for values without a normal distribution. To investigate the
differences within the groups, the paired samples t-test was
used for values with a normal distribution and the Wilco-
xon test was used for values without a normal distribution.
Repeated measurement results that did not have a normal
distribution were analysed using the Friedman Test. The
error level for all analysis was set at P = 0
05. The results
were analysed using SPSS, version 15.0 (SPSS Inc., Chicago,
IL, USA). A nurse who was independent from the study
evaluated and calculated VAS and ODI scores. All statisti-
cal analysis was done with accompaniment of an epidemiol-
ogy expert.
Results
Study sample
We invited 209 women to participate, of whom 54 women
could not participate or declined to participate and 59
women were excluded for various reasons. A total of 96
women were available for the baseline measurement and
were randomized. The flow of participants through the
study is shown in Figure 1.
The characteristics of participants analysed on an inten-
tion-to-treat basis (n = 96) are shown in Table 1 (Montori
& Guyatt 2001). At the beginning of the study, there was
no statistically significant difference between the two
groups with regards to any of the possible confounding
variables (To & Wong 2003, Wang et al. 2004, Wu et al.
2004, Albert et al. 2006, Bjelland et al. 2011, Chang et al.
2012). The characteristics of the participants in the two
groups were similar at the beginning of the study. No
baseline differences in Visual Analogue Scale during
relaxation-VASrelaxation–1 score (z = 1
355; P = 0
176),
Visual Analogue Scale during activity-VASactivity–1 score
(z = 0
018; P = 0
985) and Oswestry Disability Index-ODI1
score (t = 0
641; P = 0
523) were observed between the
intervention group and the control group initially (Table 1).
The effects of the exercise program on pain intensity
and functional status
For the control group, the Visual Analogue Scale during
relaxation (VASrelaxation–1) was 42
77 (26
57) at baseline
and increased to 49
02 (24
89) VASrelaxation–2 at the final
(z = 1
271, P = 0
204) and the baseline Visual Analogue
Scale during activity (VASactivity–1) was 59
81 (22
60) and
7
S. Ozdemir et al.

Table 1 Characteristics of the study sample (n = 96).

Control (n = 48) Intervention (n = 48)
 (SD)
X min–max  (SD)
X P Test value P

Age 30
10 (4
26) 21–38 29
15 (5
39) 18–42 0
965* 0
337

BMI1 (kg/m2) 24
05 (3
79) 15
67–31
56 22
85 (4
02) 16
80–37
04 1
792† 0
073
BMI2 (kg/m2) 27
49 (3
96) 17
96–34
01 26
22 (3
86) 19
53–37
46 1
582* 0
116
Parity (n) 0
98 (0
81) 0–2 0
71 (0
77) 0–2 1
655† 0
098
Gestation (week) 27
27 (5
26) 20–35 26
13 (4
74) 20–35 1
018† 0
309
Gestational age that pains started in 20
23 (6
48) 4–32 19
29 (5
88) 5–34 0
720† 0
471
VASrelaxation–1 (mm) 42
77 (26
57) 0–100 50
44 (26
92) 0–100 1
355† 0
176
VASactivity–1 (mm) 59
81 (22
60) 10–100 60
71 (22
53) 13–100 0
018† 0
985
ODI1 31
29 (7
04) 15–46 32
25 (7
59) 19–50 0
641* 0
523

Control (n = 48) Intervention (n = 48)

n % n % X† P

Parite
Nullipar 16 33
3 23 47
9 2
787 0
248
Primipar 17 35
4 16 33
3
Multipar 15 31
3 9 18
8
Family structure
Nuclear 46 95
8 44 91
7 0
711 0
390
Large 2 4
2 4 8
3
Education
≤8 years 11 22
9 5 10
4 2
70 0
100
8 years< 37 77
1 43 89
6
Work situation
Worker 8 16
7 10 20
8 0
274 0
601
Non-worker 40 83
3 38 79
2
Perceived of economic situation
Inadequate 8 16
7 9 18
8 0
071 0
789
Adequate 40 83
3 39 81
2
Smoking
Non-smoker 34 70
8 32 66
6 0
196 0
906
Quit smoking in pregnancy 8 16
7 9 18
8
Smoker 6 12
5 7 14
6
Previous low back and pelvic pain story during pregnancy ‡(control n = 32, exercise n = 25)
Yes 13 40
6 12 48
0 0
310 0
578
No 19 59
4 13 52
0
Definition of low back and pelvic pain
Burning 5 10
4 3 6
2 0
874 0
832
Sharp 21 43
8 21 43
8
Blunt 4 8
3 3 6
2
Tingling 18 37
5 21 43
8
The time period that low back and pelvic pain was the most severe
Morning 2 4
2 4 8
4 4
433 0
218
Midday 11 22
9 11 22
9
End of day 11 22
9 18 37
5
Night 24 50
0 15 31
3

8 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: CLINICAL TRIAL Pregnancy-related low back and pelvic pain

Table 1 (Continued).
Control (n = 48) Intervention (n = 48)

n % n % X† P

The frequency of low back and pelvic pain

Continued 8 16
7 4 8
3 1
835 0
607
Often 11 22
9 10 20
8
Sometimes 25 52
1 30 62
5
Rarely 4 8
3 4 8
3

*Student t-test.
†
Mann–Whitney U-test
‡
Women who have previously at least one live birth were included in.
BMI1, body mass index at the beginning of pregnancy; BMI2, body mass index at the beginning of the study; VASrelaxation–1, the average
pain score during rest at the beginning of the study; VASactivity–1, the average pain score during activity at the beginning of the study; ODI1,
the average ODI score at the beginning of the study; X2, Pearson chi-square test.

Table 2 The comparison of the study variables obtained at baseline and at the end of study.
Control (n = 48) Intervention (n = 48)
 (SD)
X Test value P  (SD)
X Test value P

VASrelaxation-1 42
77 (26
57) 1
271† 0
204 50
44 (26
92) 4
347† 0
001*

VASrelaxation-2 49
02 (24
89) 29
75 (23
84)
VASactivty-1 59
81 (22
60) 1
132† 0
258 60
71 (22
53) 4
829† 0
001*
VASactivty-2 62
50 (21
31) 35
40 (23
57)
ODI1 31
29 (7
04) 0
608‡ 0
546 32
25 (7
59) 4
970‡ 0
001*
ODI2 31
96 (7
12) 26
40 (8
03)

*P < 0
05.
†
Wilcoxon test.
‡
Paired samples t-test.

at the end of the study VASactivity–2 was 62
50 (21
31)
(z = 1
132, P = 0
258) (Table 2).
For the intervention group, there was a statistically signif-
icant difference in both the Visual Analogue Scale during
relaxation (VASrelaxation) scores (z = 4
347, P = 0
001) and
Visual Analogue Scale during activity (VASactivity) (z =
4
829, P = 0
001) scores when compared with the baseline
scores (Table 2).
For the control group, the baseline mean ODI1 score was
31
29 (7
04) and the final ODI2 score was 31
96 (7
12)
(t = 0
608, P = 0
546). For the intervention group, the
baseline the mean ODI1 score was 32
25 (7
59) and the
final ODI2 score was 26
40 (8
03), with a statistically sig-
nificant difference between these two results (t = 4
970,
P = 0
001) (Table 2).
At the end of the study, there was a statistically signifi-
cant difference between the control and intervention groups
with regards to the Visual Analogue Scale during relaxation
(VASrelaxation–2) (z = 3
598, P = 0
001) scores and the
Visual Analogue Scale during activity (VASactivity–2)
(z = 5
090, P = 0
001) scores (Table 3). The final mean
ODI2 scores for the control group were significantly higher
than the mean ODI2 scores for the intervention group
(t = 3
588, P = 0
001) (Table 3).
The weekly changes in pain intensity for control and
intervention groups are shown in Table 4. We found a
statistically significant increase from the first mean the
Visual Analogue Scale during relaxation (VASrelaxation)
score to the last mean VASrelaxation score in the control
group (Fr = 20
461, P = 0
001). We also found a statisti-
cally significant decrease in the mean VASrelaxation score
for the intervention group over the study duration
(Fr = 58
456, P = 0
001) (Figure 3). The mean Visual Ana-
logue Scale during activity (VASactivity) scores for the con-
trol group remained at a similar level through the study
duration (Fr = 4
803, P = 0
440). We found a statistically
significant decrease in the mean Visual Analogue Scale
during activity (VASactivity) scores for the intervention
group over the study duration (Fr = 72
507, P = 0
001)
(Figure 4).

© 2015 John Wiley & Sons Ltd 9

S. Ozdemir et al.

Table 3 The comparison according to the characteristics of groups at the end of the study (I) (n = 96).
Control (n = 48) Intervention (n = 48)
 (SD)
X min–max  (SD)
X min–max Test value P

VASrelaxation–2 (mm) 49
02 (24
89) 0–100 29
75 (23
84) 0–88 3
598† 0
001*
VASactivity–2 (mm) 62
50 (21
31) 0–99 35
40 (23
57) 0–80 5
090† 0
001*
ODI2 31
96 (7
128) 21–47 26
40 (8
034) 11–44 3
588† 0
001*

*P < 0
05.
†
Mann–Whitney U-test.
VASrelaxation–2, the average of pain score during rest at the end of the study; VASactivity–2, the average of pain score during activity at the end
of the study; ODI2, the average of ODI score at the end of the study.

Table 4 The comparison of the groups’ measurements of VASrelaxation and VASactivity according to weeks at the end of study (n = 96).
VASrelaxation (mm) VASactivity (mm)
 (SD)
X  (SD)
X
(min–max) (min–max)

Control (n = 48) Intervention (n = 48) Control (n = 48) Intervention (n = 48)

First assessment 42
77 (26
57) 50
44 (26
92) 59
81 (22
60) 60
71 (22
53)
(0–100) (0–100) (10–100) (13–100)
1st week 35
44 (21
31) 50
83 (21
49) 61
10 (19
189 57
83 (21
90)
(0–81) (20–100) (10–100) (20–100)
2nd week 40
79 (24
29) 44
58 (23
53) 60
19 (19
08) 50
54 (25
04)
(0–86) (0–93) (20–100) (0–100)
3rd week 41
73 (26
00) 37
65 (23
55) 56
50 (23
86) 41
12 (25
18)
(0–89) (0–96) (0–90) (0–100)
4th week 41
50 (27
38) 35
67 (25
71) 58
25 (25
32) 40
23 (26
40)
(0–98) (0–95) (0–98) (0–91)
Last assessment 49
02 (24
89) 29
75 (23
84) 62
50 (21
31) 35
40 (23
57)
(0–100) (0–88) (0–99) (0–80)
F 20
461 58
456 4
803 72
507
P 0
001* 0
001* 0
440 0
001*

*P < 0
05.
F, Friedman test.

60 70
50 60
VAS relaxation

VAS activty

40 50
40
30
30
20
Control 20
10 Control
Exercise 10
0 Exercise
0
k k k k k k k k
t

ee ee ee ee
t

ee ee ee ee
en

en

en

en

w w w w
sm

tw w w w
m

sm

st d d h
s

4t d d h
s

2n 3r 1s 3r 4t
es

es

1 2n
es

es
ss

ss

ss

ss
ta

ta

ta

ta
rs

rs

s
La

La
Fi

Fi

Figure 3 Change in average pain intensity during rest. Figure 4 Change in average pain intensity during activity.
Additionally, low back and pelvic pain analysed (P > 0
05). At the end of the study we found that there
separately in terms of functional level or pain intensity but were not any statistical differences between exercise type in
there were not any statistical differences between them terms of pain intensity or functional status (P > 0
05).

10 © 2015 John Wiley & Sons Ltd

JAN: ORIGINAL RESEARCH: CLINICAL TRIAL
Discussion
We determined that the exercise program with individual-
ized health counselling used in this study to relieve and
resolve the severity of LBPP over 4 weeks relieved the par-
ticipants’ pain intensity and promoted their functional sta-
tus, confirming our research hypothesis. The literature
contains studies with both concordant and discordant find-
ings.
Kluge et al. (2011) reported that pregnant women in the
exercise group had decreased pain intensity and increased
functional capacity when compared with the control group
at the end of the exercise program used in their study. We
obtained similar results using a continuous health education
and individualized exercise program. We determined that
the counselling and exercise programs used in our study
could be more easily used by all pregnant women with
LBPP. Shima et al. (2007) showed that their exercise pro-
gram relieved the intensity of low back and pelvic pain for
pregnant women but did not affect their functional status
(Shima et al. 2007), while Mørkved et al. (2007) deter-
mined that their exercise program prevented the intensity of
low back and pelvic pain and improved the functional sta-
tus in one of eight pregnant women at 36 weeks of gesta-
tion. Garshasbia and Zadeh (2005) reported that exercise
relieved the severity of pregnancy-induced low back and
pelvic pain, while Depledge et al. (2005) reported that exer-
cise and health education programs would increase long-
term muscle support and might be more effective than
external supports in reducing pain. Our study demonstrated
that effective health counselling and an exercise program
easily initiated by a professional nurse showed rapid effects
by motivating pregnant women to exercise, a significant
finding of our study.
In contrast to our findings, Dumas et al. (2010) reported
that an exercise program did not relieve the severity of
pregnancy-induced low back and pelvic pain and did not
affect functional status. Similarly, Nilsson-Wikmar et al.
(2005) reported that pelvic stabilization exercises during
pregnancy and the postpartum period did not relieve the
severity of low back and pelvic pain and did not shorten
the postpartum healing process. Ostgaard et al. (1994)
reported that while individualized education, ergonomics
and exercise programs lessened the pregnant women’s need
for rest due to low back and pelvic pain, these interventions
did not relieve the pain. The difference between our find-
ings and the literature was thought to result from the meth-
odological design of the studies (Perkins et al. 1998,
Hammer et al. 2000, Sneag & Bendo 2007, Sabino &
© 2015 John Wiley & Sons Ltd
Pregnancy-related low back and pelvic pain
Grauner 2008, Nacır et al. 2009, Vermani et al. 2010).
Consequently, our study could provide data that could lead
to improvements in nursing practice.
Limitations
In this study, the data about exercise level of pregnant
women were based on their written and verbal statements.
Pregnant women were not observed during the exercise and
this condition was considered a limitation of the study.
LBPP was diagnosed according to oral patient history by
doctor.
Conclusion
As pregnancy-related LBPP is a preventable consequence of
pregnancy, pregnant women should not have to accept liv-
ing with this pain (Greenwood & Stainton 2001). Our
study demonstrated that pregnancy-related LBPP could be
relieved and functional status could be improved by regular
nurse counselling and the implementation of an individual-
ized exercise program for 4 weeks.
To relieve pregnancy-related LBPP and maintain func-
tional status, an exercise program should be effectively per-
formed, pregnant women’s exercise-related concerns should
be addressed and pregnant women should be motivated to
exercise. These interventions can be provided by correctly
identifying goals and proper nursing interventions. (Shima
et al. 2007, Evenson & Bradley 2010). Pregnancy-related
LBPP contains characteristic differences from low back pain
in the normal population. Therefore, it was hypothesized
that exercise programs for LBPP specific to pregnant
women would more effectively manage their pain. Exercise
programs used by pregnant women with LBPP can provide
significant benefits, reducing the intensity of pain by
increasing muscle strength, improving functional status and
€
increasing quality of life (Arıkan Beyaz & Ozcan 2005,
Gutke et al. 2008, Vleeming et al. 2008, Gutke et al.
2010a,b, Ji & Ha 2010).
Additionally, women who are working and have less time
to fill paper-work, digital programs may be created for fol-
low-up the exercise program. And future studies should pay
attention to pain levels which are in average level in both
groups in this study.
Funding
This research received no specific grant from any funding
agency in the public, commercial, or not-for-profit sectors.
11
S. Ozdemir et al.
Conflict of interest
No conflict of interest has been declared by the authors.
Author contributions
All authors meet at least one of the following criteria (sug-
gested by the ICMJE: from http://www.icmje.org/ethi-
cal_1author.html):
• substantial contributions to conception and design,
acquisition of data, or analysis and interpretation of
data;
• drafting the article or revising it critically for important
intellectual content and final approval of the version to
be published.
Supporting Information
Additional Supporting Information may be found in the
online version of this article at the publisher’s web-site.
References
Akbayrak T. & Kaya S. (2008) Gebelik ve Egzersiz. Saglik
Bakanligi Yayinlari, Klasmat matbaacilik, Ankara.
Albert H.B., Godskesen M., Korsholm L. & Westergaard J.G.
(2006) Risk factors in developing pregnancy-related pelvic girdle
pain. Acta Obstetricia et Gynecologica Scandinavica 85, 539–
544.
€
Arıkan Beyaz E. & Ozcan E. (2005) Gebelikte g€ or€
ulen kas-iskelet
sistemi kaynaklı agrılar ve tedavi yaklasßımları. T€urkiye Fiziksel
Tıp ve Rehabilitasyon Dergisi 51, 65–68.
Bastiaanssen J.M., de Bie R.A., Bastiaenen C.H.G., Heuts A.,
Kroese M.E., Essed G.G.M., Brandt A. & Van den Brant P.
(2005a) Etiology and prognosis of pregnancy-related pelvic girdle
pain; design of a longitudinal study. BMC Public Health 5, 1–8.
Bastiaanssen J.M., de Bie R.A., Bastiaenen C.H., Essed G.G. &
Van den Brandt P.A. (2005b) A historical perspective on
pregnancy-related low back and/or pelvic girdle pain. European
Journal of Obstetrics, Gynecology, and Reproductive Biology
120, 3–14.
Bjelland E., Eberhard-Gran M., Nielsen C. & Eskild A. (2011) Age
at menarche and pelvic girdle syndrome in pregnancy: a
population study of 74 973 women. BJOG: An International
Journal of Obstetrics and Gynaecology 118, 1646–1652.
Bj€
orklund K., Naessen T., Nordstr€ om M.L. & Bergstr€ om S. (1999)
Pregnancy-related back and pelvic pain and changes in bone
density. Acta Obstetricia et Gynecologica Scandinavica 78, 681–
685.
Carr C.A. (2003) Use of a maternity support binder for relief of
pregnancy-related back pain. JOGNN 32, 495–502.
Chang H.Y., Yang Y.L., Jensen M.P., Lee C.N. & Lai Y.H. (2011)
The experience of and coping with lumbopelvic pain among
pregnant women in Taiwan. Pain Medicine 12, 846–853.
12
Chang H.Y., Jensen M.P., Yang Y.L., Lee C.N. & Lai Y.H. (2012)
Risk factors of pregnancy-related lumbopelvic pain: a biopsy-
chosocial approach. Journal of Clinical Nursing 21, 1274–1283.
Damen L.O., Buyruk H.M., Guler-Uysal F., Lotgering F.K.,
Snijders C.J. & Stam H.J. (2001) Pelvic pain during pregnancy is
associated with asymmetric laxity of the sacroiliac joints. Acta
Obstetricia et Gynecologica Scandinavica 80, 1019–1024.
Depledge J., McNair P.J., Keal-Smith C. & Williams M. (2005)
Management of symphysis pubis dysfunction during pregnancy
using exercise and pelvic support belts. Physical Therapy 85,
1290–1300.
Dumas G.A., Leger A., Plamondon A., Charpentier K.M., Pinti A.
& McGrath M. (2010) Fatigability of back extensor muscles
and low back pain during pregnancy. Clinical Biomechanics 25,
1–5.
Elden H., Ostgaard H.C., Fagevik-Olsen M., Ladfors L. & Hagberg
H. (2008) Treatments of pelvic girdle pain in pregnant women:
adverse effects of standard treatment, acupuncture and stabilising
exercises on the pregnancy, mother, delivery and the fetus/
neonate. BMC Complementary and Alternative Medicine 8, 1–13.
Evenson K.R. & Bradley C.B. (2010) Beliefs about exercise and
physical activity among pregnant women. Patient Education and
Counseling 79, 124–129.
Fairbank J.C.T. & Pynsent P.B. (2000) The Oswestry disability
index. SPINE 25, 2940–2953.
Garshasbia A. & Zadeh S.F. (2005) The effect of exercise on the
intensity of low back pain in pregnant women. International
Journal of Gynecology and Obstetrics 88, 271–275.
Greenwood C.J. & Stainton M.C. (2001) Back pain/discomfort in
pregnancy: invisible and forgotten. The Journal of Perinatal
Education 10, 1–12.
Gutke A., Ostgaard H.C. & Oberg B. (2006) Pelvic girdle pain and
lumbar pain in pregnancy: A cohort study of the consequences in
terms of health and functioning. Spine 31, 149–155.
Gutke A., Ostgaard H.C. & Oberg B. (2008) Association between
muscle function and low back pain in relation to pregnancy.
Journal of Rehabilitation Medicine 40, 304–311.
Gutke A., Kjellby-Wendt G. & Oberg B. (2010a) The inter-rater
reliability of a standardised classification system for pregnancy-
related lumbopelvic pain. Manual Therapy 15, 13–18.
Gutke A., Sj€ odahl J. & Oberg€ B. (2010b) Specific muscle
stabilizing as home exercises for persistent pelvic girdle pain after
pregnancy: a randomized, controlled clinical trial. Journal of
Rehabilitation Medicine 42, 929–935.
Hammer R.L., Perkins J. & Parr R. (2000) Exercise during the
childbearing year. Journal of Perinatal Education 9, 1–14.
Ji E.S. & Ha H.R. (2010) The effects of qi exercise on maternal/
fetal interaction and maternal well-being during pregnancy.
JOGNN 39, 310–318.
Kalus S.M., Kornman L.H. & Quinlivan J.A. (2008) Managing
back pain in pregnancy using a support garment: a randomized
trial. BJOG: An International Journal of Obstetrics and
Gynaecology 115, 68–75.
Kanakaris N.K., Roberts C.S. & Giannoudis P.V. (2011) Pregnancy-
related pelvic girdle pain: an update. BMC Medicine 9, 1–15.
Kanık E.A., Tasßdelen B. & Erdogan S. (2011) Klinik denemelerde
randomizasyon. Marmara Medical Journal 24, 149–155.
Kluge J., Hall D., Louw Q., Theron G. & Grove D. (2011) Specific
exercises to treat pregnancy-related low back pain in a South
© 2015 John Wiley & Sons Ltd
JAN: ORIGINAL RESEARCH: CLINICAL TRIAL
African population. International Journal of Gynecology and
Obstetrics 113, 187–191.
Lindseth G. & Vari P. (2005) Measuring physical activity during
pregnancy. Western Journal of Nursing Research 27, 722–734.
Mazicioglu M., Tucer B., Ozturk A., Serin I.S., Koc H., Yurdakos K.
& Bayrak B. (2006) Low back pain prevalence in Turkish pregnant
women. Journal of Back and Musculoskeletal Rehabilitation 19,
89–96.
Mens J.M.A., Damen L., Snijders C.J. & Stam H.J. (2006) The
mechanical effect of a pelvic belt in patients with pregnancy-
related pelvic pain. Clinical Biomechanics 21, 122–127.
Mens J.M.A., Pool-Goudzwaard A. & Stam H.J. (2009) Mobility
of the pelvic joints in pregnancy-related lumbopelvic pain a
systematic review. Obstetrical and Gynecological Survey 64,
200–208.
Mogren I.M. (2000) Previous physical activity decreases the risk of
low back pain and pelvic pain during Pregnancy. Scandinavian
Journal of Public Health 33, 300–306.
Mogren I.M. & Pohjanen A.I. (2005) Low back pain and pelvic
pain during pregnancy, prevalence and risk factors. SPINE 30,
983–991.
Montori V.M. & Guyatt G.H. (2001) Intention-to-treat
principle. Canadian Medical Association Journal 165, 1339–
1341.
Mørkved S., Salvesen K.A., Schei B., Lydersen S. & Bø K. (2007)
Does group training during pregnancy prevent lumbopelvic pain?
A randomized clinical trial. Acta Obstetricia et Gynecologica
Scandinavica 86, 276–282.
Murphy D.R., Hurwitz E.L. & McGovern E.E. (2009) Outcome of
pregnancy-related lumbopelvic pain treated according to a
diagnosis-based decision rule: a prospective observational cohort
study. Journal of Manipulative and Physiological Therapeutics
32, 616–624.
Nacır B., Karag€ oz A. & Erdem H.R. (2009) Gebelikte g€ or€
ulen bel
agrıları. Turkish Journal of Rheumatology 24, 39–45.
€
Nilsson-Wikmar L., Holm K., Oijerstedt R. & Harms-Ringdahl K.
(2005) Effect of three different physical therapy treatments on
pain and activity in pregnant women with pelvic girdle pain: A
randomized clinical trial with 3, 6 and 12 months follow-up
postpartum. Spine 30, 850–856.
Olsson C. & Nilsson-Wikmar L. (2004) Health-related quality of
life and physical ability among pregnant women with and
without back pain in late pregnancy. Acta Obstetricia et
Gynecologica Scandinavica 83, 351–357.
Ostgaard H.C., Zetherstrom G., Roos-Hansson E. & Svanberg B.
(1994) Reduction of back and posterior pelvic pain in pregnancy.
Spine 19, 894–900.
Pennick V. & Liddle S.D. (2013) Interventions for preventing and
treating pelvic and back pain in pregnancy. Cochrane Database
of Systematic Reviews 8, 1–100. doi:10.1002/14651858.
CD001139.pub3.
Pennick V. & Young G. (2007) Interventions for preventing and
treating pelvic and back pain in pregnancy. Cochrane Database
of Systematic Reviews 2, 1–33. doi:10.1002/14651858.
CD001139.pub2.
Perkins J., Hammer R.L. & Loubert P.V. (1998) Identification and
management of pregnancy-related low back pain. Journal of
Nurse-Midwifery 43, 331–340.
© 2015 John Wiley & Sons Ltd
Pregnancy-related low back and pelvic pain
Pillitteri A. (2007) Promoting fetal and maternal health. In
Maternal and Child Health Nursing: Care of the Childbearing
and Childrearing Family, 5th edn (Niegiski E., ed.), Lippincott
Williams & Wilkins, Philadelphia, PA, pp. 271–297.
Potter P.A., Griffin P.A., Stockert P.A. & Hall A.M. (2013) Pain
management. In Fundamentals of Nursing, 8th edn (Potter P.A.,
ed.), Mosby Elsevier Inc, Canada, pp. 963–995.
PS Software. PS Software: Power and Sample Size Calculation, by
Vanderbilt University, Department of Biostatistics. Retrieved
from http://biostat.mc.vanderbilt.edu/wiki/Main/PowerSampleSize
on 03 May 2011.
Reeder S.J., Martin L.L. & Koniak-Griffin D. (1997) Nursing care
in the prenatal period. In Maternity Nursing: Family, Newborn
and Women’s Health Care, 18th edn (Brogan J., ed.), Lippincott-
Raven Publishers, Philadelphia, PA, pp. 396–433.
Robinson H.S., Eskild A., Heiberg E. & Eberhard-Gran M. (2006)
Pelvic girdle pain in pregnancy: The impact on function. Acta
Obstetricia et Gynecologica Scandinavica 85, 160–164.
Robinson H.S., Mengshoel A.M., Veierod M.B. & Vollestad N.
(2010) Pelvic girdle pain: potential risk factors in pregnancy in
relation to disability and pain intensity three months postpartum.
Manual Therapy 15, 522–528.
R€ost C.C.M., Jacqueline J., Kaiser A., Verhagen A.P. & Koes B.W.
(2006) Prognosis of women with pelvic pain during pregnancy: a
long-term follow-up study. Acta Obstetricia et Gynecologica
Scandinavica 85, 771–777.
Sabino J. & Grauner J.N. (2008) Pregnancy and low back pain.
Current Review Musculoskelet Medicine 1, 137–141.
Saccomanni B. (2011) Low back pain associated with pregnancy: a
review of literature. Eur Orthop Traumatol 1, 169–174.
Shima M.J., Leeb Y.S., Ohc H.E. & Kim J.S. (2007) Effects of a
back-pain-reducing program during pregnancy for Korean
women: A non-equivalent control-group pretest-posttest study.
International Journal of Nursing Studies 44, 19–28.
Sneag D.B. & Bendo J.A. (2007) Pregnancy-related low back pain.
Orthopedics 30, 839–845.
Stapleton D.B., MacLennan A.H. & Kristiansson P. (2002) The
prevalence of recalled low back pain during and after pregnancy:
a South Australian population survey. Australia New Zealand
Journal Obstetric Gynaecology 42, 482–485.
Stuge B., Hilde G. & Vøllestad N. (2003) Physical therapy for
pregnancy-related low back and pelvic pain: A systematic
review. Acta Obstetricia et Gynecologica Scandinavica 82, 983–
990.
Sullivan R., Magarick R., Bergthold G., Blouse A. & Mclntosh N.
€
(Translate edt: Ozvaris Bahar, S, Sahin N.) (1999) Tip
egitimcileri icßin egitim becerileri rehberi. Hacettepe Halk Sagligi
Vakfi Yayinlari, Ankara.
Tasßkın L. (2007) Dogum ve Kadın Saglıgı Hemsßireligi. Sistem
Ofset Matbaacılık, Ankara.
To W.W.K. & Wong M.W.N. (2003) Factors associated with back
pain symptoms in pregnancy and the persistence of pain 2 years
after pregnancy. Acta Obstetricia et Gynecologica Scandinavica
82, 1086–1091.
Vermani E., Mittal R. & Weeks A. (2010) A pelvic girdle and low
back pain in pregnancy: a review. Pain Practice 10, 60–71.
Verstraete E.H., Vanderstraeten G. & Parewijck W. (2013) Pelvic
girdle pain during or after pregnancy: a review of recent evidence
13
 S. Ozdemir et al.

and a clinical care path proposal. Facts Views Vision in Wu W.H., Meijer O.G., Uegaki K., Mens J.M.A., Van Dieen J.H.,
Obstetric Gynaecology and Reproductive Health 5, 33–43. Wuisman P.I.J.M. & Ostgaard H.C. (2004) Pregnancy-related
Vleeming A., Albert H.B., Ostgaard H.C., Sturesson B. & Stuge B. pelvic girdle pain (PPP), I: Terminology, clinical presentation and
(2008) European guidelines for the diagnosis and treatment of prevalence. European Spine Journal 13, 575–589.
pelvic girdle pain. European Spine Journal 17, 794–819. Yakut E., D€ € uz C
uger T., Oks€ ß ., Y€
or€ €
ukan S., Ureten K., Turan D.,
Wang S.M., Dezinno P., Maranets I., Berman M.R., Caldwell- Fırat T., Kiraz S., Kırdı N., Kayıhan H., Yakut Y. & G€ ß.
uler C
Andrews A.A. & Zeev N.K. (2004) Low back pain during (2004) Validation of the Turkish version of the Oswestry
pregnancy: prevalence, risk factors and outcomes. Obstetrics & disability index for patients with low back pain. Spine 29, 581–
Gynecology 104, 65–70. 585.
Wewers M.E. & Lowe N.K. (1990) A critical review of visual
analogue scales in the measurement of clinical phenomena.
Research in Nursing & Health 13, 227–236.

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