Case-Based Management of Musculoskeletal Dysfunction in The

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Objectives

Case-Based Management of Upon completion, participants should be able to: Musculoskeletal Dysfunction in the 1. Understand and apply to patient care the pathophysiology of various obstetric musculoskeletal Obstetric client disorders commonly seen in this population. 2. Practice and apply treatment interventions to the pregnant and postpartum client for these musculoskeletal dysfunctions. Jill Schiff Boissonnault, PT, PhD, WCS 3. Develop appropriate home programs for clients with such musculoskeletal dysfunction. 4. Appreciate current evidence for the interventions the participants discuss and practice

The Cases The Format

• Pregnant client with a Herniated Nucleus • Expectation of Participation-bringing the Pulposus (HNP) wisdom in the room into the course! • Post-partum client with L&D-related • Weaving into the discussion: coccydynia – Evidence • Pregnant client with Transient Osteoporosis of – Examination concerns – Intervention options (exercise, manual therapy, the Hip (TOH) belts/supports, advice) • Pregnant client with dysfunction and pain in • Lab practice: driven by discussion, the cases, her thoracic spine and ribs and participant requests/needs

Epidemiology-HNP in Pregnancy

Herniated Nucleus Pulposus in • 1/10,000 De Novo disc herniations in Pregnancy pregnancy (Laban MM, Viola S, Williams DA, Wang A. Magnetic resonance imaging of the lumbar herniated disc in pregnancy. Am J Phys Med Rehabil, 1995; 74(1): 59-61.) • Much more common to see women with previous Hx of HNP who are now pregnant

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Medical Management-HNP in Review of Osteopathic Mechanics Pregnancy • MRI safe in pregnancy as a means of Dx of • Fryette’s laws on neutral and non-neutral

HNP (LaBan 1995, Laban 1995, Weinreb 1989) mechanics

• Opiods sometimes given as pain relief (Matsumoto 2009) • Type 1 and Type 2 lesions

• Surgery is an option (Brown and Levi, 2001) • FRS and ERS • Mode of Delivery: C-Section vs. Vaginal • Sacral Torsions

• Cases of Cauda Equina (Timothy 1999, Askan 1998, Chow 2008,, Gupta 2008,) • Pubic Shears • Response of the sacrum to Lumbar spine motion

HNP in Pregnancy HNP in Pregnancy-the Case Patient Interview Findings • A 30-year-old G2PI woman presented at 22 weeks gestation with complaints of right buttock and lower extremity pain. • CC: Sharp, intermittent R LE pain and P/N and mild- • Mechanism of Injury (MOI): lifting 2–year old from floor to moderate LBP. No c/o bowel/bladder dysfunction changing table. • MOI: lifting her 2-yr old from floor • Previous Medical Hx: Mild backache in previous pregnancy • Hx: No c/o LE pain in 1st pregnancy. Had mild-moderate • Physical examination: LBP in this pregnancy prior to onset of LE pain. No previous LB or LE pain outside of pregnancies – left lateral shift • – flattened lumber lordosis Location: R lateral calf and dorsal aspects of R foot. – positive right straight leg raising at 30 ° • Aggravation: FB, sitting > 15 min, childcare, lifting – positive crossed straight leg raising at 45 ° • Alleviation: supine lying • MRI: moderate right posterolateral disk protrusion at the L4-5 • Nature: Sharp, some P/N when aggravated. Intermittent. level with probable compromise of the L5 nerve root. Ranges from 3-8 on 0-10 pain scale

HNP in Pregnancy Physical Examination Findings • Left lateral shift • Flattened lumber lordosis • Neuro exam: – Positive right straight leg raising at 30 – Positive crossed straight leg raising at 45 ° – Diminished sensation R LE in L5 distribution – DTR’s WNL • Increased T-S kyphosis , mildly increased C-S lordosis • Forward head posture • Flat feet with mild pronation bilaterally

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HNP in Pregnancy HNP in Pregnancy Physical Examination Findings-cont. PT Interventions • FRS L @ L5 • Manual Left Lateral Shift correction • PA pressure at L5 restricted and painful, Gr II • Self-Correction of lateral shift • BB exercises: 4-point; standing, leaning against • Increased paraspinal tone L low lumbar wall (with lateral shift correction); standing, • Leg Sx worsened with FB; slightly minimized leaning on table with repeated BB • Traction: in pool; holding onto doorframe (with • Shift correction → ↑LB pain, but ↓ LE Sx lateral shift correction) • Body Mechanics instruction for childcare, ADL’s • Provocation tests for PGP negetive and IADL’s, use of lumbar support • Gait is unremarkable, though slow • Lumbar support garments

Summary of Position Modifications for Women with Pre-existing Spinal or Pelvic Ring Dysfunction (Boissonnault JS, 2002) HNP in Pregnancy Dysfunction Positions to Avoid Recommended Positions Lumbar or Thoracic Disc Herniation or -Squatting -Semi-reclining/lumbar support PT Recommendations for L&D Bulge -Semi-reclining/knees to chest, -Side lying -Lithotomy and hands/knees if nerve -Hands/Knees if nerve root tension is root tension is an issue not an issue • First Stage Intervertebral Spinal Stenosis Standing -Any position that opens the intervertebral foramen; side lying with side bending to the opposite side, with – Walk, if comfortable or without flexion -Positions that encourage spinal flx; – Rest with lumbar support squatting, forward bending over the a Swiss Ball, bean-bag chair or pillows – Maintain lumbar lordosis in positioning choices Spondylolithesis Standing Any position that avoids increased lumbar spine extension – Avoid squatting or FB Sacroiliac Dysfunction Walking during first stage -Any position where the LE’s are Semi-reclining with LE’s unsupported symmetrically supported; semi- Lithotomy reclining with pillows under both • Second Stage knees -Hands/knees, upright kneel if WB OK – Push with open glottis Pubic Symphysis Dysfunction -Side lying if the LE’s are widely -Side lying if the LE’s are not widely abducted abducted – Avoid FB postures including squatting (use L-S -Squatting -Semi-reclining with knees supported -Lithotomy by pillows support, e.g., in semi-reclining -Hands/knees or upright kneel if weight bearing is comfortable Coccyx Dysfunction Semi-reclining Any position where the coccyx is free Lithotomy to move:Side lying, Squatting, Hands/knees,Upright Kneel,Standing

HNP in Pregnancy Correction of Left Lateral Shift Lab Practice • Shift-Correction options – Exercise (self correction and PT directed) – Manual correction – and muscle energy for FRS L L5 • Extension and flexion bias exercise options (McKenzie-adapted to the pregnant client) • Body Mechanics instruction • Supports/belts

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Pregnant Woman Press-Up Trunk Extension on Wall with and without shift correction

Trunk Extension in 4-Point MET: FRS correction Sidelying

PNF D2 Flx: Also an FRS L HEP

Correction of an FRS Left in Sitting

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Restoration of Trunk Flexion and Rotation in 4-Point Restoration of Trunk Flexion and Rotation in Standing

Transverse Abdominis Ex in 4-Point Transversus Abdominis Exercise While Sitting or When Driving

Body Mechanics Instruction

Auto-Traction in Doorway

How to Raise Children Without Breaking Your Back, Pirie and Herman, 1995

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CMO Mother-To-Be Support for L-S References

• Ashkan K, Casey AT, Powell M,. Crockard AH. Back pain during pregnancy and after child birth: an unusual case not Dysfunction to miss. J Roy Soc Med, 91 (1998), pp. 88–90 • Boissonnault JS. Modifying labor and delivery positions for women with spine and pelvic ring dysfunction. Jnl SOWH, 2002; 26(2): 9-13. • Brown, M.D. , Levi, A.D.O. Surgery for lumbar disc herniation during pregnancy. Spine, 2001; 26 (4): 440-443 • Chow J, Chen K, Sen R, Stanford R, Lowe S. Cauda equina syndrome post-caesarean section. Aus. N Z J Obstet Gynaecol, 2008; 48(2):218-20. • Gupta P, Gurumurthy M, Gangineni K, Anarabasu A, Keay SD. Acute presentation of cauda equina syndrome in the third trimester of pregnancy. Eur J Obstet Gynecol Reprod Biol. 2008;140(2):279-81. • LaBan MM; Rapp NS; von Oeyen P; Meerschaert JR; The lumbar herniated disk of pregnancy: a report of six cases identified by magnetic resonance imaging. Archives of Physical Medicine & Rehabilitation, 1995 May; 76 (5): 476- 9. • Laban MM, Viola S, Williams DA, Wang A. Magnetic resonance imaging of the lumbar herniated disc in pregnancy. Am J Phys Med Rehabil, 1995; 74(1): 59-61. • Matsumoto E, Yoshimura K, Nakamura E, Hachisuga T, Kashimura M. The use of opioids in a pregnant woman with lumbar disc herniation: a case report. J Opioid Manag. 2009 Nov-Dec;5(6):379-82. • McKenzie R. How To Treat Your Back , 7th edition. http://treatbackpainyourself.com/ • Timothy J, Anthony R, Tyagi A, Porter D, Van Hille PT. A case of delayed diagnosis of the cauda equina syndrome in pregnancy. Aust NZ J Obstet Gynaecol, 39 (2) (1999), pp. 260–261 • Weinreb, J.C., Wolbarsht, L.B., Cohen, J.M., Brown, C.E.L., Maravilla, K.R. Prevalence of lumbosacral intervertebral disk abnormalities on MR images in pregnant and asymptomatic nonpregnant women. Radiology, 1989; 170 (1 1): 125-128.

Nathan et al, 2010. Coccydynia: a Post-partum Coccydynia review of pathoanatomy, aetiology, treatment and outcome

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Epidemiology & Pathophysiology of Coccydynia Etiology & Pathology Post-partum Coccydynia • After external trauma, • Risk factors: BMI > 27, delivery appears to be the Parity >2, FORCEPS • Theory of “coccygeal instability”= luxations nd 2 most common cause DELIVERY, ventouse (Maigne and hypermobility (> 25° of flx) of coccydynia in women 2012) • MOI: Fx & soft tissue – MRI study (Maigne , Spine 2000) trauma 2◦ pressure of the • Obstetric-related – Debated by some (Grassi 2006) presenting part (Kaushal 2005) coccydynia is reported to • Anatomical variations → ?↑ risk (Postachini 1983,Woon be 3-15% (Maigne 1996 & 2012, Thiele 1963, • Role of maternal position 2012) Bayne 1984,Peyton 1988, Wray 1991, Zayer 1996) (theoretical-JB) – ↑ Risk: Lithotomy on delivery • Role of body mass index: ↑ risk (Maigne, Jnl Bone Jt Surg • Prevalence in vaginal births: table & Semi-reclining on a birthing bed 2000) Unknown (Ryder, 2000) – Protective: bottom off any (Maigne, Jnl Bone Jt Surg 2000, surface (squatting, 4-point, • Role of coccygeal trauma sidelying, upright kneeling, Nathan 2010) standing)

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Medical Management of Post-partum Evidenced-Based PT Intervention for Coccydynia Postpartum Coccydynia • Intrarectal manual treatment • Physical Agents for associated Levator • Steroid injection to SC jt. : Pts with < 6 mos. pain (Maigne 2006, 2012. Marinko 2014) Ani Syndrome or PFM hypertonus: – Mobilization of the coccyx via are good candidates (Mitra, 2007) muscle contraction (proposed, but not well researched) – Mobilization of the Sacrum at the -High volt electrical stimulation - • NSAIDS SC Jt while holding the coccyx Iontophoresis (see chart on next still intrarectally slide) • Coccygectomy- Doursounian 2004 good ref: – Distraction of the coccyx Surgery only in those refractory to conser. care with/without lateral deviation -TENS – Ventral/caudal glides -interferential therapy • Referral to PT (usually categorized as diathermy with/without distraction -Pulsed electromagnetic energy and electrical stimulation) - US • Intrarectal Soft Tissue Mobilization • Post-partum doughnut (Thiele 1937, 1963) (Stephenson 2008, Johnson 2006)

• Intra-rectal manipulation • Assessment and Rx of bowel • Positioning-multiple authors; no dysfunction especially to avoid research given (De Andre´s 2003, Hodges 2004, Doursounian 2004, Mitra 2007, Nathan 2010) constipation (Lande 2011)

Most current reference with good lit review: Johnson and Rochester, 2006

The Case • 38 yr old Gravida 6, Para 4, 8 weeks postpartum. Pt. is stay-at-home mom and investment consultant working from home • CC: Coccyx pain @ 5/10 • Hx of CC: Pt. noticed the pain day 2 pp. Pain has remained the same since. • Rx to date: ice, Tylenol 3, donut from hospital • Pt. Goals: Sit at home office desk >2 hrs; Sit to nurse baby without pain (As seen in Michlovitz, Bellew and Nolan, 2012)

Patient Interview Findings: Post- Physical Exam Findings: Post-partum partum Coccydynia Coccydynia-Visit 1 • Location of Pain: Coccyx and surrounding buttock • Palpation: tender all around coccyx externally; area. C/o pain with her one attempt at intercourse (last wk) since the birth of the baby Exquisite tenderness at SC jt line • Nature: deep ache; constant when seated • Springing SC jt: Painful and reproduces her pain • Agg: sitting > 5 minutes (nursing, work); hard • Sitting Posture: Antalgic surfaces worst • Alev: ice, meds, getting off bottom • Observation: Pt. can contract PF mm but not • Radiograph negative for Fx clear how well she relaxes • Orthopaedist offering coccyjectomy if PT is unsuccessful

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PT Interventions: Post-partum PT Visit 2 Assessment: Post-partum Coccydynia-Visit 1 Coccydynia • Unweight the coccyx in sitting • Internal rectal exam – Cushion or toweling – Assessed coccyx position: slight deviation to the – Provide lumbar support to maintain lordosis Right • Review sitting postures in all activities – Pain along ventral margin of SC jt line – Work, nursing, eating meals, driving, etc. – Pain in coccygeus mm bilaterally – PF mm contraction: 4/5 strength, 10 sec hold, 10

reps, but unable to fully relax (could not feel a softening of the tissues-finger unable to sink in)

PT Visit 2-6: Post-partum Coccydynia, PT Recommendations for L&D- Client cont. with Hx of Coccydynia • Rx: • First stage and second stage avoidance of – Biofeedback with rectal probe to down-train PFM, specifically, coccygeus direct pressure on coccyx – Reviewed sitting posture • Positioning options: – Began first of 6 visits of iontophoresis with TMJ-size electrode and dexamethazone to SC jt – Squatting or sitting on a birthing stool • Prevention – Sidelying – Discussed need to let tissues heal and avoid prolonged – Upright kneeling pressure on coccyx for many months, even if pain is 0/10 – 4-point – Future births: she planned on one more child: – Standing discussed positioning for L&D next time

Post-partum Coccydynia References • Bayne O, Bateman J, Cameron H 1984 The infuence of etiology on the results of coccygectomy. Clinical Orthopaedics and Related Research 190: Post-partum Coccydynia -Lab Practice 266±272 Peyton 1988, • De Andre´s J, Chaves S. Coccygodynia: A Proposal for an Algorithm for Treatment. The Journal of Pain, Vol 4, No 5 (June), 2003: pp 257-266 • Doursounian L, Maigne JY, Faure F, Chatellier G. Coccygectomy for instability of the coccyx. Int Orthop. 2004 Jun;28(3):176-9 • Grassi R, Lombardi G, Reginelli A, et al. Coccygeal movement: assessment with dynamic MRI. Eur J Radiol. 2007;61:473-479. • Hodges SD, Eck JC, Humphreys SC. A treatment and outcomes analysis of patients with coccydynia. Spine J. 2004 Mar-Apr;4(2):138-40. • Johnson A; Rochester AP; Coccydynia. Journal of the Association of Chartered Physiotherapists in Women's Health, 2006 Spring; (98): 44-52. • External palpation of PF contraction • Kaushal R, Bhanot A, Luthra S, Gupta PN, Sharma RB. Intrapartum coccygeal fracture, a cause for postpartum coccydynia: a case report. J Surg Orthop Adv. 2005 Fall;14(3):136-7. • Lande J, Clinton S, Borello-France D. Physical therapy treatment of a patient with a diagnosis of coccydynia. Jnl Wom Health Phys Ther 35(1), 2011, 24–36 • Unweighting the coccyx in sitting • Maigne JY, Doursounian L, Chatellier G. Causes and mechanisms of common coccydynia: role of body mass index and coccygeal trauma. Spine (Phila Pa 1976). 2000;25:3072-3079. • Maigne JY, Lagauche D, Doursounian L. Instability of the coccyx in coccydynia. J Bone Joint Surg Br. 2000;82:1038-1041. • Maigne JY, Chatellier G, Le Faou M, Archambeau M. The treatment of chronic coccydynia with intrarectal manipulation: a randomized controlled study. Spine 2006; 31(18); E621-E627. • Maigne JY. Postpartum coccydynia: a case series study of 57 women. Eur J phys rehab med 2012: 48(3); 387-392. • Marinko LN, Matthew P. Clinical decision making for the evaluation and management of coccydynia: 2 case reports. JOSPT 2014: 44(8); 615-21. • Mitra R, Cheung L, Perry P. Efficacy of fluoroscopically guided steroid injections in the management of coccydynia. Pain Physician. 2007;10:775-778. Michlovitz SL, Bellew JW, Nolan Jr. TP. Eds. Modalities for therapeutic Intervention, 5th ed. FA Davis Co, Philadelphia 2012,. • Nathan ST; Fisher BE; Roberts CS. Coccydynia: A review of pathoanatomy, aetology, treatment and outcome. Journal of Bone & Joint Surgery, British Volume, 2010 Dec; 92 (12): 1622-7. • Postacchini F, Massobrio M. 1983. Idiopathic coccygodynia. Analysis of fifty-one operative cases and a radiographic study of the normal coccyx. J Bone Joint Surg Am 65:1116–1124. • Ryder I, Alexander J. Coccydynia: a woman’s tail. Midwifery, 2000. Vol: 16 (2), pg 155-160 • Stephenson RG, Shelly ER. Electrical stimulation and biofeedback for genitourinary dysfunction. In, Robinson AJ, Snyder-Mackler L, eds. Clinical Electrophysiology, 3rd ed. Lippincott Williams & Wilkins, Wolters Kluwer, Philadelphia 2008. • Thiele G 1963 Coccygodynia: cause and treatment. Diseases of the Colon and Rectum 6: 422±436 • Thiele GH. Coccydynia and pain in the superior gluteal region and down the back of the thigh: causation by tonic spasm of the levator ani, coccygeus and piriformis muscles and relief by massage of these muscles. JAMA 1937;109: 1271–5. www.sears.com www.indiamart.com • Woon JT, Stringer MD. Clinical anatomy of the coccyx: a systematic review. Clin Anat. 2012;25:158-167. http://dx.doi.org/10.1002/ ca.21216 • Wray C, Easom S, Hoskinson J 1991 Coccydynia, aetiology and treatment. Journal of Bone and Joint Surgery 73 (2): 335±338 • Zayer M 1996 Coccygodynia. Ulster Medical Journal 65 (1): 58±60Maigne J, Tamalet B 1996 Standardized radiologic protocol for the study of common coccydynia and characteristics of the lesions observed in the sitting position. Spine 21 (22): 2588±2593

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Transient Osteoporosis of the Hip What is TOH? (TOH) in Pregnancy • TOH is a subset of Osteoporosis in pregnancy • Other osteoporetic areas seen in pregnancy: – Lumbar spine – Wrist – Tibia • Diagnosis made by MRI, radiographs (pp), bone scans, and R/O diagnosis • Referred as transient osteoporosis during pregnancy due to the self-limiting nature and spontaneous recovery. • Fractures are infrequent (1%) • True incidence during pregnancy is unknown

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Pathophysiology of TOH in Pregnancy A Genetic Link?

• CA requirements to mineralize a fetal skeleton should • Carbone, et al, 1995. Described two patients not challenge maternal bone stores of CA (Sowers, 2000) with osteoporosis during pregnancy. – Maternal skeleton calcium store is approximately 1000 Daughters demonstrated osteopenia at the grams. – 30 grams of calcium are required for fetal skeleton wrist as did the two patients at 10 year FU. mineralization • Dunne, et al, 1993. Studied 35 women with Hx • Theory of pregnancy related osteoporosis. Found a – Women with osteopenia or bone density challenges who significantly higher prevalence of Fx occurring become pregnant are at risk for osteoporosis in pregnancy (Drinkwater 1991, Khastgir, 1996) at a younger age in the mothers of these – Genetic link (Carbone 1995, Dunne 1993) women. – Chemical/Hormonal mediation? (Chigira, 1988)

Risk Factors for Osteopenia during Medical Management of TOH in Pregnancy Pregnancy • Family history • Imaging: only if they suspect a Fx. Likely wait • Immobilization/inactivity (bed rest in high risk pregnancies) until pp • Dietary deficiencies (Ca intake below 1200-1500mg, ↓Vitamin D) • Rest and restricted WB (NWB or WB as • Toxins (tobacco and alcohol) Tolerated) with assistive devices prn • Medications (anti-coagulants-thromboemboli) • Work restrictions as needed • Comorbidities • Postpartum: imaging, bisphosphonates (rare), calcium, calcitonin, continued WB restrictions and gait-aid prn

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TOH Presentation and Prognosis The Case • 32 year old, gravida 1, para 0, 29 weeks Common presentation (Samdani, 1998) gestation. • Onset: Generally in 3rd trimester • • Pain locale: inguinal or greater trochanteric credit records specialist (sits all day) regions with referral to anterior thigh. • Referred to PT from Nurse midwife/Obstetrician • ROM: limited at the hip 2 weeks prior to initial PT visit • Functionally restricted weight bearing Prognosis • Diagnosis of “R sciatica”. Pt. had been seen in Recovery from 2 to 12 months post-partum and PT before for same Dx, but on the Left. may be prolonged due to lactation (Carbone 1995, • PMH: L -S HNP (1996), forearm Fx age 19 Drinkwater1991,Dunne 1993, Funk 1995, and Sowers 1996) 5 1 (Boissonnault W, 2001, Boissonnault J, 2005)

Patient Interview Findings- TOH in Pregnancy • Chief complaint: Deep right groin pain varying from 4-9/10, sharp and throbbing , “deep inside my hip”. • Groin symptoms present for 4 weeks, initially as intermittent stiffness, then, 10 days prior to PT, became intense and sharp. • Insidious groin stiffness/pain onset.

Aggravating & Alleviating Factors Pt. Interview: Secondary Symptoms TOH Case TOH Case • Aggravation: • Ache: low lumbar, right buttock and lateral thigh, – Standing: 10 minutes intensity of 2-5/10. – Walking: 2-3 blocks • Insidious onset 12 weeks prior to initial PT visit – Transitional movements (approximately 17 weeks gestation) – Activities of daily living such as dressing that • Slow, progressive worsening required hip flexion • Aggravated by sitting > 10 min., F-Flex postures • Alleviation: • Alleviated by changing positions, supine lying – Sitting – Recumbency

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Pt. Interview: Secondary Symptoms, Differential Diagnosis continued, TOH Case • Paresthesia right lateral lower leg with • Origin(location) of CC considered: insidious onset 12 weeks prior to initial PT 1.Pubic Symphysis visit. 2.SIJ ® • Aggravated by sitting > 10 minutes and F-Flx 3.Lower T-spine/L-Spine postures 4.® hip joint or soft tissue lesion • Alleviated by recumbency • Previous Hx: similar Sx in Left LE 1996 NOTE: Use of patellar-pubic percussion test (PPPT) would help R/O Fx

Physical Examination Findings TOH Physical Exam, continued Case TOH Case • Slow, antalgic gait • Trunk ROM: CC provoked with FB and right SB; • Stance: minimal WB on Right LE limited in FB, Right SB and BB (with c/o right • Palpation: moderate to severe tenderness L/S pressure) right femoral triangle • SLR ®: CC provoked at 30o • Pubic Symphysis non-tender to palpation • SIJ screening/provocation tests were neg. and springing • Neuro exam: decreased light touch right, lateral lower leg; right Achilles reflex 1+

Physical Exam, continued Physical Exam, continued Hip ROM, TOH Case End Feel, ® hip, TOH Case Motion Right Hip Left Hip (AA/P ROM) (AROM) • Empty end feel: with hip flx and IR, and SLR to o Flexion 85/85 125 30 Internal Rotn 5/5 40 • Spasm end feel: with hip abduction External 50/55 55 • Capsular end feel: with ER and extension Rotn Abduction 20/20 45 Extension 5/8 15 Adduction NT NT

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Assessment of Clinical Presentation PT Interventions and Medical TOH Case Management, TOH Case Symptoms Signs • Crutches • Sudden onset of CC • Severe ROM loss ® hip • Off work with decrease in Sx • Insidious onset of CC • Empty end feel Flx, IR, SLR • Seen 10 days PP in PT S/P vaginal delivery with • Severe pain, 9-10/10 • Spasm end feel Abd similar presentation, so referred back to CNM/OB with subsequent referral to an Orthopedist. • No relief of pain with rest • Prov. CC SLR 30o • Subsequent Plain films and MRI suggested TOH:  • Inability to actively lift ® LE BMD in femoral head, neck, and acetabulum without collapse. • MD and CNM unaware of  Pt.Sx • Lab tests negative

Referral Generated back to CNM with specific concerns about R hip

1-2 weeks postpartum: MRI coronal image of the pelvis and hips. Note bone marrow edema of the 1 week Postpartum: Conventional radiograph of the pelvis and hips. The 3 arrows identify the osteopenia proximal right femur (upper shaft, femoral neck, and head) and the right hip joint effusion when of the right proximal femur and acetabulum when compared to the corresponding areas of the left hip. compared to the corresponding areas of the left hip. No evidence of fracture or avascular necrosis was noted.

Management of TOH, Postpartum

• WB to tolerance with crutches • Aquatic PT for ambulation, strengthening, ROM and pain relief. • FU plain films at 10 weeks pp • FU MRI at 12 weeks pp • Told to progress to land-based program to rebuild bone density (Pt. moved away after this) 1-2 weeks postpartum. MRI axial image of the right hip. Note bone marrow edema of the right femoral head and the right hip joint effusion.

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Follow-up conventional radiograph of the pelvis and hips taken approximately 13 weeks after the initial MRI axial follow-up of the right hip taken approximately 3 months after the initial radiograph. According to the radiologist, this radiograph revealed normal mineralization of the physical therapy visit. slight residual high-signal intensity area in the right femoral head right femur and acetabulum. and acetabulum noted by the radiologist.

PT Recommendations for L&D- TOH in TOH in Pregnancy -Lab Practice Pregnancy • Semi Reclining with hip supported by pillows • Assess end feels in hips (Flx, ext, abd, IR, ER) in Flx, (limited) AB and ER • Palpation: about hip joint region • Avoid WB postures and consider hip ROM • Provocation tests to R/O pelvic jts limitations – Spring pubis • Regional Anesthesia concerns: no pain – Sacrum: spring ILA’s, apex and Sacral Sulci in feedback sitting

• Patellar-pubic percussion test (PPPT) (File, 1998)

(Magee,2002)

Springing the Sacrum in Sitting

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Patellar Pubic Percussion Test TOH References

• Boissonnault WG, Boissonnault JS. Transient Osteoporosis of the Hip Associated with Pregnancy JOSPT. 2001;31(7):359-367 • Boissonnault JS; Boissonnault WG; Bartoli P; Osteoporosis During the Childbearing Year. Journal of Women's Health Physical Therapy, 2005 Winter; 29 (3): 28-32. • Khastgir G, Studd JW, King H, et al. Changes in bone density and biochemical markers of bone turnover in pregnancy-associated osteoporosis. Br J Obstet Gynaecol. 1996;103:716-718. • Drinkwater BL, Chestnut CH. Bone density changes during pregnancy and lactation in active women: a longitudinal study. Bone Miner. 1991;14:153-160. • Chigira M, Watanabe H, Udagawa E. Transient osteoporosis of the hip in the first trimester of pregnancy. A case report and review of Japanese literature. Arch Orthop Trauma Surg. 1988;107:178-180. • Carbone LD, Palmieri G, Graves SC, Smull K. Osteoporosis of pregnancy: long-term follow-up of patients and their offspring. Obstet Gynecol. 1995;86:664-666. • Dunne F, Walters B, Marshall T, Heath DA. Pregnancy associated osteoporosis. Clin Endocrinol (Oxf). 1993;39:487- 490. • File P, Wood JP, Kreplick LW. Diagnosis of hip fracture by the ausculatory percussion technique. Am J Emerg Med. 1998;16 (2):173-176. • Magee 2002 • Samdani A, Lachmann E, Nagler W. Transient osteoporosis of the hip during pregnancy: a case report. Am J Phys Med Rehabil. 1998;77:153-156. • Funk JL, Shoback DM, Genant HK. Transient osteoporosis of the hip in pregnancy: natural history of changes in bone mineral density. Clin Endocrinol (oxf). 1995;43:373-382. • Sowers M. Pregnancy and lactation as risk factors for subsequent bone loss and osteoporosis. J Bone Miner Res. 1996;11:1052-1060.

Thoracic Spine and Ribcage Anatomic Thoracic Spine and Ribcage Dysfunction in Pregnancy Change in Pregnancy • Anatomical changes in Ribcage during pregnancy – Costal angles – Dimension changes – Costal vertebral joints – Costal transverse joints (Strahaul 2011) • Thoracic Spine Changes: – ↑ T-S kyphosis

(Bullock 1987, Franklin 1998) www.whittlesey-osteopaths.com (deSwiet 1991) • NO WONDER THERE IS DYSFUNCTION!

Medical Management of Thoracic The Case Spine and Ribcage Dysfunction ’ • 31 yr old Gravida 1 para 0, office worker @ 32 • NONE! “Live with it” mentality wks gestation • Common dysfunction and complaint in pregnancy; probably 2nd or 3rd in incidence after • CC: Mid back pain, intra-scapular and PGP and LBP complaints sometimes left ribcage, posterior-laterally • Remember to screen for medical disease! (Boissonnault • MOI: insidious and Stephenson, 2010) visceral sources of T-S/rib-cage pain: • Hx: Began 6 weeks ago and has ↑ in intensity. – Gallbladder No c/o back pain prior to pregnancy – Upper urinary tract infection • Pt. goal: to be able to continue working until – AAA delivery; to ↓ pain – Heart

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Patient Interview Findings- Thoracic Physical Exam Findings- Thoracic Spine Spine and Ribcage Dysfunction and Ribcage Dysfunction • Pain is intermittent and 2-8/10; worse at end • Intra-scapular pain reproduced by AROM of of work day T-S in FB, SB and Rotation bilaterally • Agg: computer work, doing dishes • Central PA’s and Left Unilateral PA’s are stiff (gr • Alev: sleep (once it comes), local heat, spouse 11) @ T 5-8 massaging area • Springing ribs 6-8 on left reproduce some of her • Function: pt. reports difficulty doing her unilateral pain computer work due to pain; Feels she needs • Position testing: FRS L T6,7 AND ERS L T5 (YIKES!) to lie down once she gets home at the end of • C-S is clear as are shoulder joints. PA’s to lumbar day, and has trouble falling asleep due to pain spine are negative

PT Interventions- Thoracic Spine and PT Interventions- Thoracic Spine and Ribcage Dysfunction Ribcage Dysfunction, cont. • Muscle energy techniques in sitting for FRS • General Trunk Strengthening and ERS positional findings – Core Stabilization • AAROM to T-S and ribcage in sitting • HEP for T-S and • Back extensor strengthening with ribcage mobility theraband/tubing • Considerations for • Ergonomic assessment of her work station and sleep (foam mattress pad) posture with recommendations for (Boissonnault, 2011) modifications prn

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PT Recommendations for L&D- Thoracic Body Mechanics Instruction for Post-partum Child Care Spine and Ribcage Dysfunction • Most likely, no modifications needed • Encourage partner to monitor her posture and to manage any c/o T-Spine pain with massage and heat

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Thoracic Spine and Ribcage Dysfunction -Lab Practice • FRS and ERS assessment in sitting ERS Correction • FRS T-S correction in sitting in Sitting • ERS T-S correction in sitting • AAROM for T-S/rib cage – Elongation in sitting – T-S Rotation – T-S extension over PT’s knee • HEP for T-S SB, Rot, BB • TRa strengthening & pelvic tilts on wall • Posture re-education

Active Assisted Trunk SB FRS Correction in Sitting

Elongation in Sitting to ↑ SB Active Assisted Vertebral Extension

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Active Assisted Trunk/Vertebral T-S Self-Mobilization into Extension Rotation

PA Unilateral Pressures in Supported Chair Twist to ↑Trunk Rotation Lean

Transverse Abdominis Ex in 4-Point Transversus Abdominis Exercise While Sitting or When Driving

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Posture Work and Abdominal Posterior Pelvic Tilt on the Wall Strengthening to ↓Excessive L-S Lordosis

Thoracic Spine and Ribcage Dysfunction References

• Boissonnault JS. Physical Therapy Management of Musculoskeletal Dysfunction During Pregnancy. In Irion JM, Irion GL, Women’s Health in Physical Therapy. 2010. Lippincott, Williams, and Wilkins, Philadelphia, PA. • Boissonnault JS, Stephenson RG. The obstetric patient. In, Boissonnault W., ed., Primary Care for the Physical Therapist. Examination and Triage. 2011. Elsevier, St Louis MO. • Bullock JE, bullock MI. the relationship of low back pain to postural changes during pregnancy. Aust J Physiother 1987; 33:10-17. • deSwiet M. the respiratory system. In Hyten FE, Chamberlain G, eds: Clinical Physiology in obstetrics, 2nd ed, Oxford, England, 1991, Blackwell Scientific, p 88. • Franklin ME, Conner-Kerr T. An analysis of posture and back pain in the first and third trimesters of pregnancy. JOSPT 1998; 28(3): 133- 138. • Strauhal MJ. Therapeutic exercise in obstetrics. In, Therapeutic Exercise. Moving Toward Function, 3rd Ed. Brody LT, Hall CM, eds. Wolters kluwer/Lippincott Williams & Wilkins, Philadelphia PA 2011.