Original Article
Correlation Between the Intensities of Pregnancy - Related Low Back Pain and Urinary Incontinence in Pregnant and Postpartum Women in Enugu, Nigeria
Authors:
Chukwu Sylvester Caesar, Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus,
Ojukwu Chidiebele Petronilla, Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus,
Ezeagu Nkechi Ebere, Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus,
Okemuo Adaora Justina, Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus,
Ikele Ikenna Theophilus, Department of Anatomy, Faculty of Basic Medical Sciences, University of Nigeria, Enugu Campus,
Igwe Sylvester Emeka, Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus,
Onuchukwu Chioma Linda, Department of Physiotherapy, Enugu State University Teaching Hospital, Parklane Enugu,
Ikele Chioma Nneka,
Department of Medical Rehabilitation, Faculty of Health Sciences and Technology, University of Nigeria, Enugu Campus.
Address for Correspondence
Ojukwu Chidiebele Petronilla,
Department of Medical Rehabilitation,
Faculty of Health Sciences and Technology,
University of Nigeria, Enugu Campus,
Enugu, Nigeria.
E-mail: chidiebele.ojukwu@unn.edu.ng.
Citation
Chukwu CS, Ojukwu CP, Okemuo AJ, Ikele IT, Igwe SE, Onuchukwu CL, Ikele CN. Correlation Between the Intensities of Pregnancy - Related Low Back Pain and Urinary Incontinence in Pregnant and Postpartum Women in Enugu, Nigeria. Online J Health Allied Scs.
2019;18(1):11. Available at URL:
https://www.ojhas.org/issue69/2019-1-11.html
Submitted: Mar 2,
2019; Accepted: Apr 16, 2019; Published: Apr 30, 2019 |
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Introduction:
Pregnancy elicits several physiological changes with resultant effects in various body systems, including cardiovascular, endocrine, renal and musculoskeletal systems.(1) Distinct hormonal changes accompanied by physical changes, including body weight gain and shift in the body’s centre of gravity result in distinct biomechanical alterations (2) during pregnancy. Alterations in the body biomechanics are known precursors of musculoskeletal disorders. Among the myriad of musculoskeletal disorders experienced during pregnancy, low back pain (LBP) is one of the most common reported by pregnant women.(3-5)
Low back pain experiences may range between bursts of chronic pain and disabling pain during pregnancy and for a variable period postpartum (6). LBP during pregnancy may be as a result of mechanical, hormonal and other factors, associated with the changes of the body. It is a disabling condition, limiting everyday activities and impacting productivity. Literature is replete on the aetiology and associated factors of LBP in the childbearing years.(3,7) However, controversies exist in causes and pathophysiology of pregnancy-related LBP. While some studies suggest hormonal factors (6), others implicate mechanical factors (7,8,9) or both (1) as causes of LBP in the child-bearing years. Relative to the mechanical factors, one of the most frequent mechanisms attributes pregnancy-related physical changes (weight gain, increase in abdominal sagittal diameter and consequent anterior shift of the body’s centre of gravity center) to increased stress on the lower back (9), pubic symphysis disorders (7) and postural alterations. In compensation of the pregnancy-related physical changes, postural adjustments may be implemented which typically result in lordosis with additional stress on the lower back (8). Other mechanical factors have been suggested as causes of LBP in the childbearing years. Some include the roles of the abdominal (9), gluteus (10) and pelvic floor (11) musculature as well as venous congestion in the pelvis and lumbar spine resulting from compression of the vena cava by the enlarging uterus (12). However, most of these factors, including the role of the pelvic floor musculature on pelvispinal stability have been understudied.
Management options for LBP in the childbearing years vary and usually involve conservative methods including use of physical agents, orthotic devices, moderate pharmacological treatment and therapeutic exercises (12) as well as weight loss strategies (6). Most of these treatment options are related to the knowledge of the causative factors of LBP among the affected women. Anecdotally, common strategies in the management of LBP in the childbearing years include postural training, back and abdominal exercises, use of heat and cold packs as well as reduced physical activities. Despite the reported roles of the pelvic musculature on pelvispinal stability (11), less attention has been focused on enhancing its functions as a mechanism for reducing LBP in the childbearing years.
The pelvic floor muscles have several functions, including structural support for the pelvic organs and the pelvic openings (urethra, vagina and anus), stabilizing the urethra (13), trunk and lumbopelvic stability (14). Dysfunctions in the pelvic floor muscles result in Urinary Incontinence (UI) during the childbearing years. Urinary incontinence is the involuntary loss or leak of urine. Prevalence of UI has been reported among pregnant and postpartum women in several studies (15). Occasionally, UI has been reported to co-exist with LBP in the childbearing years (1). Some studies have also suggested possible relationships between UI and LBP during pregnancy (1,11,16) reported that women with pre-existing UI have increased risk for development of LBP and vice versa. Conversely, such relationships have been understudied in the postpartum population. Despite these few reports on existing relationships between LBP and UI, women’s health practices, especially in Nigeria have been deficient in assessing the functions of and managing the pelvic floor muscles as means of improving low back symptoms in pregnant and postpartum women. Improved understanding and knowledge of the relationship between LBP and UI is necessary to modify management of LBP in the pregnant and postpartum population. This study was therefore designed to evaluate the correlation between the intensities of pregnancy related LBP and UI in pregnant and postpartum women.
Methods
This cross-sectional survey involved one hundred and fifty (150) women (pregnant-103; postpartum-47) who were conveniently recruited from three health centres in Enugu State, Nigeria. Women who had LBP, UI, spinal and pelvic floor disorders prior to their first pregnancy and/or not related to pregnancy, childbirth, or postpartum were excluded from the study. This study was approved by the University of Nigeria Medical Research and Ethics Committee and respondents gave written informed consents prior to participation in the study.
A 19-item questionnaire consisting 3 sections was used to collect data for this study. Section A - sought information on respondents’ biodata and obstetric characteristics. Section B –included a numerical pain intensity rating scale (where 1 represents mild intensity, and 5 - severe intensity) for assessing LBP intensity. Section C adopted the short form of an International Consultation on Incontinence Questionnaire [ICIQ] (17). ICIQ comprised 7 questions and was used to assess mode and severity of UI as well as its impact on women’s quality of life (QoL).
Data Analysis
Data from the questionnaire were reduced and the ICIQ responses were scored on a scale of 0 – 21, with higher scores indicating more severity of UI symptoms. Descriptive statistics of mean, standard deviation, frequency and percentages were used to summarize data. Spearman rank correlation was used to determine association between intensities of LBP and each of degree and types of UI. Alpha level was set at 0.05. Statistical test was carried out using Statistical Package for Social Sciences, version 21.0 (SPSS Inc.Chicago, IL, USA).
Results
Table 1 shows the descriptive statistics of respondents’ general characteristics. Respondents’ obstetric characteristics are presented on Table 2. Majority of the pregnant women were in their 3rd trimester (66.0%), multiparous (40.8%), had about 1 – 3 children (53.4%), multigravida (60.2%) and started antenatal clinic at their 2nd trimesters (50.5%). Also, majority of the postpartum women were multiparous (72.3%), had about 1 - 3 children (87.2%), and underwent spontaneous vaginal deliveries (72.3%).
| Table 1: General Characteristics of the Participants |
| Variable |
Pregnant (n=103) |
Postpartum (n=47) |
Age (years) |
28.89 ± 4.80 |
29.89 ± 5.69 |
Height (m) |
1.62 ± 0.06 |
1.61 ± 0.06 |
Weight (kg) |
77.72 ± 11.72 |
72.72 ± 12.45 |
BMI (kg/m2) |
29.59 ± 4.06 |
28.09 ± 4.48 |
| Key- BMI-Body mass index; values are presented as mean ± standard deviation |
| Table 2: Obstetric Characteristics of Respondents (N=150) |
| Variables |
Pregnant (n=103) |
Postpartum (n = 47) |
Trimester |
First trimester |
5 (4.9) |
- |
Second trimester |
30 (29.1) |
- |
Third trimester |
68 (66.0) |
- |
Number of birth |
Nulliparous |
41 (39.8) |
_ |
Primiparous |
20 (19.4) |
13 (27.70 |
Multiparous |
42 (40.8) |
34 (72.3) |
Number of children |
None |
41 (39.8) |
0 (0.0) |
1-3 |
55 (53.4) |
41 (87.2) |
4 and above |
7 (6.8) |
6 (12.8) |
Number of pregnancy |
Primigravida |
41 (39.8) |
- |
Multigravida |
62 (60.2) |
- |
Antenatal |
Before 1 month |
2 (2.0) |
- |
1-3 months |
33 (32.0) |
- |
4-6 months |
52 (50.5) |
- |
7-9months |
16 (15.5) |
- |
Delivery mode |
Spontaneous |
- |
34 (72.3) |
Caesarean section |
- |
13 (27.7) |
Delivery place |
Hospital |
- |
47 (100) |
Home |
- |
- |
Others |
- |
- |
| Key: Values are represented as frequency (percentage) |
Table 3 shows distribution and intensity of LBP among pregnant and postpartum women. Majority (pregnant-86.4%, postpartum-97.9%) reported LBP. All the pregnant women (100%) reported that the LBP commenced during pregnancy while most (54.3%) of the postpartum women reported commencement of LBP after pregnancy. Greater percentage of the pregnant (40.5%) and postpartum (39.1%) women reported moderate and mild LBP intensity, respectively.
| Table 3: Distribution and Intensity of LBP among Pregnant and Postpartum Women |
| Variables |
Pregnant |
Postpartum |
Low back pain |
(n =103) a |
(n=47)a |
Yes |
89 (86.4) |
46 (97.9) |
No |
14 (13.6) |
1 (2.1) |
Onset |
(n=89)b |
(n=46)b |
During pregnancy |
89 (100.0) |
21 (45.7) |
After pregnancy |
- |
25 (54.3) |
Intensity |
Mild |
26 (29.2) |
18 (39.1) |
Low |
16 (18.0) |
4 (8.7) |
Moderate |
36 (40.5) |
14 (30.4) |
Less severe |
6 (6.7) |
4 (8.7) |
Severe |
5 (5.6) |
6 (13.1) |
| Key: a -total respondents studied; b– no of respondents that have low back pain. LBP- Low back pain. Values are represented as frequency (percentage) |
Table 4 represents degrees and types of UI among pregnant and postpartum women. Most (pregnant – 60.8%; Postpartum – 81.0%) of the respondents experienced mild degree of UI while majority (pregnant – 72.5%; postpartum 71.4%) reported of stress UI. The co-existence of LBP and UI among the women are presented on Table 5. For majority (pregnant - 50.5%; postpartum- 55.3%) of them, LBP occurred without symptoms of UI.
| Table 4: Degree and Types of UI among Pregnant and Postpartum Women |
| Variables |
Pregnant |
Postpartum |
UTI |
(n=103)a |
(n=47)a |
Yes |
51 (49.5) |
21 (45.7) |
No |
52 (50.5) |
26 (55.3) |
ICIQ score (Degree) |
(n=51)b |
(n=21)b |
1-7 (Mild) |
31 (60.8) |
17 (81.0) |
8-14 (Moderate) |
20 (39.2) |
4 (19.0) |
15-21 (Severe) |
0 (0.00) |
0 (0.0) |
Types of UI |
(n=51)b |
(n=21)b |
Urge |
14 (27.5) |
6 (28.6) |
Stress |
37 (72.5) |
15 (71.4) |
Mixed |
0 (0.0) |
0 (0.0) |
| Key: a – total no of the respondents; b – no of respondents that has UI. UI-urinary incontinence; ICIQ - International Consultation on Incontinence Questionnaire scores; values are presented as frequency (percentages). |
| Table 5 Co-Existence of LBP and UI among Pregnant and Postpartum Women |
| Variables |
Pregnant (n=103) |
Postpartum (47) |
LBP with UI |
37 (35.9%) |
20 (42.6%) |
LBP without UI |
52 (50.5%) |
26 (55.3%) |
UI without LBP |
14 (13.6%) |
1 (2.1%) |
| Key: LBP: Low back pain; UI: urinary incontinence; values are presented as frequency (percentages). |
Table 6 shows correlation test results among intensities of LBP, degrees and types of UI reported by the respondents. The results show that for both groups of women, there were no significant correlations (pregnant: P = 0.324; postpartum: P = 0.464) between intensities of LBP and degrees of UI. However there was a significant correlation between intensities of LBP and types of UI (p= 0.041*) among pregnant women whereas there was no significant correlation between intensities of LBP and types of UI (p= 0.529) among the postpartum women.
| Table 6: Correlation among intensities of low back pain, degrees and types of urinary incontinence among respondents. |
| Correlation |
Pregnant |
Postpartum |
Intensities of LBP and degrees of UI |
|
|
r- value |
0.098 |
0.109 |
p- value |
0.324 |
0.464 |
Intensities of LBP and types of UI |
|
|
r-value |
-0.202 |
-0.094 |
p-value |
0.041* |
0.529 |
| Key: * represent significance at P =0.05; LBP- low back pain; UI- urinary incontinence |
Discussion
This study aimed at determining the correlation between the intensities of pregnancy-related Low Back Pain (LBP) and Urinary Incontinence (UI) in Nigerian pregnant and postpartum women. The results revealed high prevalence of LBP among the women, with a higher prevalence demonstrated in the postpartum women. This finding is concurrent with previous studies (1,12,18,19) that reported LBP as one of the most common obstetric conditions in both pregnant and postpartum women. Pregnancy-related LBP has been attributed to several factors including, a forward shift of the centre of gravity with increasing foetal and uterine sizes resulting in postural changes with resultant compensations; hormonal influences on the musculoskeletal tissues; maternal body weight gain; poor postural adaptations particularly during activities of daily living, among others. The roles of these obstetric changes and adaptations as possible aetiologic factors of pregnancy-related LBP were also evident from the results which revealed that for most women, the reported LBP commenced during pregnancy. The preponderant reports of moderate and mild intensity LBP among the pregnant and postpartum women corroborate previous studies (1,20) which reported mild and moderate LBP intensity among women during the child-bearing years.
This study also revealed a moderate prevalence of UI among the women, particularly the pregnant women. This finding agrees related studies (11,20,21) which identified UI as a common obstetric condition during gestation and beyond. The ICIQ scores of the women in the present student revealed that a majority of them experienced mild UI symptoms. Stress UI was also identified as the most common type of UI among the women, as compared to urge and mixed UI. Previously, stress UI has been reported as the most prevalent type of UI during the child-bearing years, as compared to other types of UI (15,22).
A greater percentage of the women in the present study experienced LBP without symptoms of UI. However it was also revealed that respectively, 35.9% and 42.6% of pregnant and postpartum women reported LBP coexisting with UI symptoms. Coexistence of both conditions have been reported in related studies (2,11,18,20,23), previously. Smith et al. (24) posited that “women with UI were more than twice as likely to experience frequent back pain as were women without UI”. Eliasson et al. (11) also opined that “more than three quarters of women with low back pain also experienced UI”. Co-existence of both conditions is attributable to several factors, most of which are common in or inherent of LBP and UI conditions individually. Such factors include, altered trunk muscle control (25), delayed or inadequate activation of the core muscles (16), impairments of the respiratory and pelvic floor muscles (25). The roles of these factors in the coexistence of LBP and UI are explained by the established relationship between the trunk and pelvic floor muscles. Under normal circumstances, voluntary activation of the pelvic floor muscles creates a co-contraction in the abdominal muscles (26) while voluntary activation of the lower abdominal muscles also creates reflex activation of the pelvic floor muscles (27). It has also been explained that control of the pelvis directly influences trunk flexor/extensor activation patterns (16). It can then be summarized that the pelvic floor muscles whose dysfunction results in UI plays a vital role in spinopelvic stability which when altered, results in LBP.
Conclusion
There is an incidence of LBP and UI in pregnant and postpartum mothers. Both conditions co-existed in some of the women, with preponderance in the postpartum women. There was no association between the intensity of LBP and degrees of UI in both populations. However, the intensity of LBP was associated with the types of UI experienced by the pregnant women. more studies are recommended for further exploration of the relationship between these two conditions in pregnant and postpartum women.
Acknowledgement
The authors are very grateful to all the pregnant and postpartum women who participated in this study.
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