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Prenatal Pelvis Pain

History: 

A 36 year-old woman in her third trimester of pregnancy (32 weeks) presented with sudden onset of severe left lower back and hip pain.  She was experiencing severe sharp pain with sitting, standing, walking, and general everyday activities. This resulted in her inability to work (full-time attorney) and care for her 3 year old child and household. The only thing that decreased her symptoms was lying down on her right side with pillows supporting her head and back.  She reported no previous history of back or hip pain. Because her pregnancy was not high risk, explain her doctor prescribed physical therapy. She occasionally took Tylenol for pain relief.

Patient Goals:

Decrease and/or eliminate her pain allowing her to commute to and from work, perform her daily work and home responsibilities, and be able to sleep on her left side without discomfort.

Evaluation:

The patient did not demonstrate signs of lower back nerve involvement, such as sciatica, or disc herniation. Her back (right and left), and L buttock, hip, lower abdominal muscles were severely tender upon palpation with the presence of several trigger points (exquisitely tender knots within a taut muscle band) which reproduced her pain symptoms. She demonstrated a decreased range of motion and stiffness of her spine and L hip.  Pain avoidance was noted, such as sitting on her R buttock.  This made her back muscles to actively lift her L hip off the exam table.  She also held her mid and upper back rigidly straight and took short and shallow breaths into her upper chest. She was unable to contract her abdominal core muscles in any position and the attempts to do so increased her pain levels. Her gait was a severe waddle with both hips and feet turned outwards and showed a reluctance to bear weight on her L leg. Walking reproduced the sharp pain.

Treatment: 

The patient attended physical therapy 2-3 times a week for 4 weeks. I used soft tissue mobilization and trigger point release to address her low back and left hip pain.  At the same time, I also addressed her breathing mechanics by using manual techniques to improve her rib cage mobility and diaphragm use.  Diaphragmatic breathing quiets the nervous system, promotes relaxation and decreases pain.  Postural re-education was initiated to decrease her back and hip muscle tightness.  This would allow her to assume a more efficient posture.  In addition, manually guided movement re-education exercises for her spine, hips, and legs were introduced to improve her limited range of motion and optimize her gait pattern.  She was instructed a home exercise program designed to follow through and make progress independently without causing pain. Once her pain levels were manageable, our treatment sessions focused on activating previously inhibited core and hip muscles, improving her stability and movement control.

Outcomes: 

Her pain levels decreased significantly in the first four sessions. After 1.5 weeks of absence from work, she was able to tolerate sitting and commuting to and from work. She had learned how to use diaphragmatic breathing to manage pain. As she gained strength and stability, she was able to resume walking and taking care of her 3-year-old.  Having gained breath control and the ability to use her core muscles significantly decreased the patient’s fear of the upcoming labor.