Medical

Communication

Biosci. Biotech. Res. Comm. 11(3): 469-475 (2018)

Effect of pelvic  oor exercise on non-speci c lower

back pain in post-partum women

Nitesh Malhotra

* and Aksh Chahal

Ph.D Scholar, Department of Physiotherapy, Shri Jagdishprasad Jhabarmal Tibrewala University

Department of Physiotherapy, Shri Jagdishprasad Jhabarmal Tibrewala University Jhunjhunu, Rajasthan–333001

ABSTRACT

The present aim of the study was to investigate improvement in pain intensity and measure disability of women with

constant postpartum lower back pain after and tailored exercise protocol. Herein, 30 women aged between 30-35

years having lumbo-pelvic pain after delivery of three years were included and were received tailored exercises.

The subjects were classi ed acoording to Demographic and Anthropometric characteristics. Manual Screening for

pain was done through VAS (visual analog scale) and Oswestry disability questionnaire. Group A and Group B were

classi ed as according to the exercise protocols. Group A were subjected to pelvic  oor exercise along with abdomi-

nal muscle strengthening while Group B were subjected to Spinal hyperextensions along with abdominal muscle

strengthening. The results depicted that the pelvic  oor exercise in combination abdominal exercise with routine

treatment for back pain provide signi cant bene ts in terms of pain relief and disability over routine treatment as

compared to spinal hyperextensions along with abdominal muscle strengthening. A correlation was also established

between the changes in disability and pain intensity in between two groups.

KEY WORDS: PELVIC FLOOR EXERCISE, SPINAL HYPEREXTENSIONS, POST PARTUM WOMEN, LOWER BACK PAIN

469

ARTICLE INFORMATION:

*Corresponding Author: malhotra.nitesh@gmail.com

Received 7

July, 2018

Accepted after revision 12

Sep, 2018

BBRC Print ISSN: 0974-6455

Online ISSN: 2321-4007 CODEN: USA BBRCBA

Thomson Reuters ISI ESC / Clarivate Analytics USA and

Crossref Indexed Journal

NAAS Journal Score 2018: 4.31 SJIF 2017: 4.196

Online Contents Available at: http//www.bbrc.in/

DOI: 10.21786/bbrc/11.3/16

INTRODUCTION

Back pain is common phenomenon in female which is

experienced during postpartum and is expected to pro-

long for 4-6 months affecting activities of daily living.

The majority of women recover from pregnancy related

mechanical lumbo-pelvic pain within 6 months of deliv-

ery However, studies show that 25 % of females still

have persistent non-speci c lower back pain 2-3 years

after delivery and which interferes with their daily activ-

ities (Tersi et al., 2015, Corso et al., 2016 and Gausel

et al., 2016).

470 LOWER BACK PAIN IN POST PARTUM WOMEN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Nitesh Malhotra and Aksh Chahal

The pelvic  oor is the area underneath the pelvis

which consists of muscles and connective tissues a

complex structure. It provides support to the abdominal

viscera including uterus, bladder and other viscera. The

core muscles include pelvic  oor muscles, transverse

abdominis, multi dus, internal and external oblique,

rectus, abdominus, erector spinae, quadratus lumbo-

rum, lattismus dorsi, and gluteus maximus. The muscles

involved in lower back pain are erector spinae, oblique

muscles. Since the core muscles and back muscles are

involved into spinal rotation, so they are related to each

other, (Javadian et al., 2015, Chevidikunnan et al., 2016

and Teymuri et al., 2018).

The lower back is related to multiple factors which

recount dynamic instability of pelvis and hormonal

changes this joint instability initiate the deep muscle

activation which demonstrates the sacroiliac stiffness,

based on the earlier studies guided exercises for pelvic

 oor and abdominal are recommended. Consequently,

the design of the study should be suitable with observa-

tion of relation between motor control and reduction in

symptoms. Only few studies describe tailored exercises

therapy for strengthening pelvic  oor muscles and spi-

nal stability and methods adapted are kegel’s exercise

protocol, spinal extension and abdominal strengthening.

The intervention adapted should target the outcomes

throughout the whole intervention period (Portney

et al., 2014, Tondel et al., 2016 and Bhadauria et al.,

2017).

The exercises protocol adapted to activated the

group of deep and super cial muscles which results

in improvement in the ODQ and pain score also dem-

onstrating core strengthening exercise of conven-

tional exercises (Saragiotto et al., 2016, Ferla et al., in

2016), also improving on the biomechanics (Bi et al.,

2013) also some author established more emphasis

should be given over the exercise during the third tri-

mester of pregnancy where chances of weight increase

are more established. (Domenjoz, 2014 & Kolu, 2014).

Also pelvic  oor exercise for organ prolapse and urinary

incontinence plays an important role in improving the

symptoms and to treat musculoskeletal and movement

impairments in women (Kurz et al., 2017). The weak-

ness of pelvic  oor muscles and relationship of urinary

incontinence was established in both men and women

and importance of screening of back pain in patients

with urinary incontinence (Cassidy et al., 2017)

The aim of the present study was to investigate weekly

improvement in pain intensity and measure disability of

women with constant postpartum lower back pain after

and tailored exercise protocol. A secondary aim was to

establish correlation between the changes in disability

and pain intensity in between two groups.

MATERIALS AND METHODS

30 women after lumbo-pelvic pain after delivery of

three years were included in the study and received tai-

lored exercises. The subjects aged between 30-35 years

were included in the study. The study was performed

at RLJT Hospital & Research Centre, Jhunjhunu. Exclu-

sion criteria BMI > 25, traumatic backache history of

neurological or autoimmune disorder, history of Pelvic

organ prolapse, respiratory or metabolic disease The

experiment was conducted on the basis of Demographic

data and Anthropometric characteristics of the subjects

was recorded including Name, Age, Gender, Height and

Weight, therefore BMI was also recorded prior to the

study. Manual Screening for pain was done through VAS

(visual analog scale) and Oswestry disability question-

naire.

Visual analogue scale (VAS) - the pain scale was used

to measure the degree of pain, after presenting the pain

levels on a straight line of 10 cm without gradation. The

calculations were done as 0 presenting as no pain and

10 presenting as extreme unbearable pain. The mark-

ing were made from 0-10 in centimeters, (Kersten et al.,

2014).

Oswestry Low Back Pain Disability Questionnaire-

The instrument was developed to illustrate functional

disability and to measure the clinical reduction and

improvement lower back pain. It a self questionnaire to

be  lled by the patient based on the disability faced dur-

ing activities of daily living, the questionnaire includes

10 questions related to pain management, personal care,

walking, sitting, standing, sleeping, and social life with

a scoring from 0-5 for every question with a total scor-

ing of 50.Thirty women with non speci c chronic LBP

were recruited and randomly assigned into two groups,

an experimental group A (n=15) and experimental group

B (n=15). The assessment was performed in crook lying

position, Pre and post data was collected before inter-

vention, pain intensity was measured on Visual Ana-

logue Scale (VAS) and functional disability was assessed

using Oswestry Disability Questionnaire (Pereira et al.,

2017).

Total protocol was performed for 8 weeks

Group A: Pelvic  oor exercises:

Women in this group were explained the importance of

exercises, anatomy of pelvic  oor exercises. The patients

were taught to contract their pelvic  oor muscles and to

squeeze with maximum applied effort and hold for 3-4

seconds without holding the breath.

1st phase: The patients were asked to complete 15-20

repetition in sitting and lying for 2-3 sets in a day for

 rst 3 weeks in crook lying positions

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS LOWER BACK PAIN IN POST PARTUM WOMEN 471

Nitesh Malhotra and Aksh Chahal

Table 1. Illustrates the demographic data and

anthropometric data of the subjects

Characteristics Group A Group B

Age (Mean ± SD) 33.77±1.44 32±1.46

Height (In cm) (Mean ± SD) 164±7.89 154.44±5.06

Weight (In kg) (Mean ± SD) 64±8.14 60.5±8.54

BMI (Mean ± SD) 23±4.58 25.73±2.49

phase: For 4

-6

week onwards the repetition were

increase nearly double and as per the comfort of the

patient completing 2-3 times in a day, patient were

advice to practice the session in two positions i.e. sitting

and lying

phase: 7

week onwards the patient was asked to

increase the no. of repetition to 40-50 with same no. of

sets in a day and continued till end of 8

week, patient

was advice to continue the exercises in lying , sitting

and standing

Abdominal exercises:

A. Pelvic tilt:

• Subject lies in supine lying position with knees

 exed, arm placed on the side.

• Subjects were push the lower trunk into the  oor

and contract the abdominal and glueteal muscles,

with rotating the pelvis upwards and inward and

making a bridge back off from the  oor , the same

position is holded for 5 seconds each and relax

period of 5 seconds repeating 10 times for 2- 3

times in day.

B. Partial curls:

Subjects is asked to lie down supine with knees  exed,

arms are extended the subject is asked to rest hands over

the legs and then sliding the  ngers over the knees with

 exion of the trunk and slightly lifting the shoulders,

exercises should be repeated 10 times with 2-3 sets in a

day .Subjects were instructed not to hold breath in any

exercises.

C. Diagonal curls:

Subject in supine lying position with arm in forwards

position , subject is asked to lift the shoulder off the

 oor bringing the left shoulder towards the right knee

and vice-versa then repetition for 10 times for 2-3 times

in a day

Group B:

Women in this group are trained for back extensor exer-

cise along with abdominal muscle strengthening.

Spinal hyperextensions: Subjects were asked to lie down

in prone position with hand on side, keeping weight on

the hands were asked to lift and extend the spine and

hold for 5-10 second repeating the process for 10 times

and 2-3 times in a day.

Prone on elbows: Subjects were asked to lie down in

prone position with elbow on side, keeping weight on

the elbow were asked to lift and extend the spine and

hold for 5-10 second repeating the process for 10 times

and 2-3 times in a day.

Abdominal exercises: Isometrics abdominals: Subjects

were asked to lie down supine with knee  exed and hands

under the lower back, they were told to contract the ante-

rior abdominal muscles and pres the hand with the back,

holding the position for 5-10 second and repeating the

same exercise at least 10 times for 2-3 sets in a day dur-

ing the exercises the breath holding should be avoided

followed by same abdominal exercise taught to group A

RESULTS AND DISCUSSION

Data analysis: The data analysis was done using Sta-

tistical Package for Social Sciences software Version 19

applying the descriptive data included mean standard

deviation was also calculated with paired t test and

ANOVAs test were applied to calculate the difference

between pre and post treatment intra groups. The data

was analyzed using with t-value in inter group and in

intra group using F distribution value and the F-crit

value. The result will be signi cant at p < .05.and if

p>0.05 considering it non- signi cant.

Subjects (30) were included in the study with mean

age of 33.77 ±1.44 in Group A and 32±1.46 in Group

B years. The mean height calculated was 164±7.89 and

cm and 156.44±7.59 cm, mean weight was 62±9.50 and

60.5±8.54 in kg, The mean BMI was also calculated as

23±4.58 and 25.73±2.49 respectively for group A and B.

As shown in table 2 and 3 there is signi cant effect

on the VAS score of the patient at baseline in both the

experimental Group A & B, there was an signi cant dif-

ferent seen in the score in experimental group A, but

there was no signi cant improvement seen in the ODQ

in group B

As explained in table 4 the difference within the group

for VAS score that the mean square between treatments,

2.7 not much larger is than the mean square within treat-

ments, 1.02381. The F value for VAS i.e. MSB/MSW after

the treatment is 2.63. The values showed not much vari-

ability between treatment groups and within treatment

groups. The smaller the ration less con dent the score are

Nitesh Malhotra and Aksh Chahal

472 LOWER BACK PAIN IN POST PARTUM WOMEN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

Table 2. Illustrates Group A-Experimental group (VAS and Oswestry

Disability Questionnaire)

MEAN SS⁄df T VALUE P VALUE

Visual Analog scale (VAS) -3.07 0.78 8.829 < 0.00001

Oswestry Disability

Questionnaire (ODQ)

-26.13 34.55 10.508 < 0.00001

Table 3. Illustrates Group B-Experimental group (VAS and Oswestry

Disability Questionnaire)

MEAN SS⁄df T VALUE P VALUE

Visual Analog scale (VAS) -3.73 0.92 9.427 < 0.00001

Oswestry Disability

Questionnaire (ODQ)

-2.07 14.50 0.53036 <0.3002

FIGURE 1. Illustrate the pre and post VAS scores for Experimental group A

FIGURE 2. Illustrate the pre and post ODQ scores for Experimental group A

Nitesh Malhotra and Aksh Chahal

BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS LOWER BACK PAIN IN POST PARTUM WOMEN 473

FIGURE 3. Illustrates the pre and post VAS scores for Experimental group B

FIGURE 4. Illustrates the pre and post ODQ scores for Experimental group B

Table 4. The above two table illustrate the comparison between groups and within groups

Source of Variation for VAS SS df MS F P-value F crit

Between Groups 2.7 1 2.7 2.637209 0.115593 4.195972

Within Groups 28.66667 28 1.02381

Total 31.36667 29    

Source of Variation for ODQ SS df MS F P-value F crit

Between Groups 3349.633 1 3349.633 54.9206 4.53E-08 4.195972

Within Groups 1707.733 28 60.99048

Total 5057.367 29    

Nitesh Malhotra and Aksh Chahal

474 LOWER BACK PAIN IN POST PARTUM WOMEN BIOSCIENCE BIOTECHNOLOGY RESEARCH COMMUNICATIONS

rejecting the H1 and accepting the H0 hypothesis ,stat-

ing there was no difference in VAS score in between two

group A and B showing similar results. Secondly the P

value is more than the signi cant the p-value is 0.115593.

The result is not signi cant at p < .05. The difference

within the group for ODQ score that the mean square

between treatments 3349.633, much larger is than the

mean square 60.99048 within treatments The F value for

ODQ i.e. MSB/MSW after the treatment is 54.9206. As the

value shows much variability between treatment groups

and within treatment groups. The larger the ratio more is

the con dence of score in rejecting the H0 and accepting

the H1 hypothesis, stating there was a difference in ODQ

score in between two group A and B. The f-ratio value is

54.9206. The p-value is < .00001. The result is signi cant

at p < .05.

We hereby discuss that pelvic  oor muscles make up

a large part of the body’s core, which is the foundation

for all movement, balance, stability and  exibility. The

pelvic  oor muscle exercise protocol used in the pre-

sent study was designed to co-activate super cial, deep

core muscles and abdominal exercises which resulted

in signi cantly better improvements in pain scores and

ODQ score. Javadian et al., (2015) compared with routine

treatment with back extension exercise and abdominal

exercises. Back function parameters were improved

over 8 weeks regular exercise protocol from baseline

in group A, with signi cant between-group differences

In the previous studies VAS and Oswerty disability

index was used to demonstrate the effect of pelvic  oor

exercises, (Mohammad et al., 2011 & Teymuri et al.,

2018).

These results are consistent with the  ndings of oth-

ers, who demonstrated the superiority of a pelvic  oor

strengthening protocol to over spinal extension exer-

cises for LBP. Others have suggested, however, that

pelvic  oor exercises do provide bene t over conven-

tional physiotherapy exercises in terms of pain or dis-

ability reduction (Bi et al., 2013 & Bhadauria et al.,

2017).

A spinal extension exercises protocol comprising

exercises every day for 8 weeks was found to provide no

additional signi cant improvement in ODQ score com-

pared with routine treatment. The more intense training

and longer treatment period (a minimum of 15 contrac-

tion cycles/day for 12 weeks) may explain the signi -

cant improvements in pain and disability seen in the

present study. Improving the biomechanical characteris-

tics of muscles in patients with LBP may require longer

duration in case of patients treated with spinal extension

exercises

The current studies also have some limitations. The

sample size was too small to draw any  rm conclusions.

Finally, as the study population included patients with

nonspeci c low back pain, it is not possible to general-

ize these  ndings to those with low back pain of speci c

cause.

CONCLUSION

In conclusion, the PFM exercises in combination

abdominal exercise with routine treatment for back

pain provide signi cant bene ts in terms of pain relief

and disability over routine treatment. Also it may be

recommended that PFM exercises should be an routine

protocol for any mechanical lumbo-pelvic pains. Fur-

ther, larger-scale studies with long-term follow-up are

required before these  ndings can be applied to a wider

patient group.

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