Ozdemir Et Al-2015-Journal of Advanced Nursing PDF
Ozdemir Et Al-2015-Journal of Advanced Nursing PDF
Ozdemir Et Al-2015-Journal of Advanced Nursing PDF
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Keywords: pregnancy-related low back and pelvic pain, exercise program, nurse
Aim
• Not using other methods for the treatment low back
and pelvic pain.
The aim of this study was to evaluate the effect of exercise
programs on pregnant women with pregnancy-related
Interventions
LBPP. Hypotheses of the study were: (1) Exercise programs
relieve the intensity of LBPP in pregnant women; and (2) Participants diagnosed with pregnancy-related LBPP by a
Exercise programs promote functional capacity for pregnant doctor and with no medical obstacles to participation in
women with LBPP. the study were directed to nurse. The nurse invited the
Excluded (n = 113)
Declined to participate (n = 54)
Pregnant women with pregnancy-related LBPP (N = 96) Not meeting eligibility criteria (n = 43)
Randomized (N = 96)
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)
pregnant women to the research room for a discussion on choice of two types of exercise according to the weather
low back and pelvic pain. After the eligibility criteria of the conditions. The first option comprised exercises performed
pregnant women were reviewed, initial assessments were on a mattress, including stretching, tightening and loosening
completed and the participants were subsequently random- movements that targeted large muscle groups from the neck
ized (Figure 1). to the vertebrae. The nurse explained that the mattress
The nurse gave health counselling to the participants in exercises would start with a 5 minute warm up, continue
the intervention group about the prevention of pregnancy- for at least 15-20 minutes at mid-tempo and end with a
related LBPP and initiated an exercise program that 5 minute cool down. The second option was a walking
included exercise training. The health counselling and exer- exercise. The participants were expected to warm up for
cise training booklets provided were prepared based on the 5 minutes, increase their speed for 5 minutes, continue at
literature (Wang et al. 2004, Pillitteri 2007, Akbayrak & mid-tempo for 15 minutes and complete a 5 minute cool
Kaya 2008, Vermani et al. 2010). Each counselling session down. It was emphasized that the pulse rate should be
lasted an average of 45 minutes. Sessions were completed between 120-160/min when the participants reached mid-
in a positive education atmosphere and were face-to-face as tempo. In this exercise program, we assumed that both the
consistent with the principles of adult education (Sullivan walking exercise and the mattress exercises had equal
et al. 1999). The structure and function of the vertebrae, effects on the low back and pelvic pain. Pregnant women
physical changes occurring during pregnancy, causes of were able to choose the type of exercise according to their
pregnancy-related LBPP, the problems that the pain causes, wishes and requirements and could use either or both of
methods of pain management, correct posture development, the exercise options. The nurse determined the exercise plan
body mechanics during activities of daily life and ergonom- with the pregnant women, creating an individual exercise
ics were explained to the pregnant women using illustrated program according to the patient’s personal characteristics.
booklets given during the trainings. During the counselling, The participants were asked to record the type and the
the nurse received information from the participants about duration of the completed exercises during the program on
their daily activities and educated the participants about the the data collection form and were asked to note if they
behaviours that might damage the low back and pelvic encountered any problems during the program. The nurse
regions. Participants were given practical demonstrations of taught the participants how to complete the forms and
how to move and how to protect the low back and pelvic answered any questions about the programs. The nurse
regions during daily life. For example, the nurse demon- spoke with the pregnant women on the phone three times a
strated how to retrieve an object from the ground, how to week and gave counselling according to their needs. During
reach shelves, how to sit and stand up and how to lie interviews, pregnant women were reminded to complete the
down, guiding the participants through these activities as data collection forms. After 4 weeks, the researchers made
well. The participants’ questions were answered and they a final assessment of the pregnant women and collected the
were given educational booklets. Following the health con- forms during a face-to-face interview. The exercise pro-
sultation, exercise education was given. The participants grams were terminated at this point, though (Figure 1) the
were given illustrated booklets explaining the effects of pregnant women were able to continue the counselling if
pregnancy exercises on maternal and foetal health, situa- they wished. At the end of the study, pregnant women in
tions that need attention before starting and during exer- the intervention group were asked to note if they meet any
cises, signs of danger, what should be done in potentially side effects of the exercise. There was not any negative
dangerous situations, how to breathe during exercise and feed-back about the exercise program.
the method, frequency and amount of the exercise. The The pregnant women in the control group received usual
exercises given to the intervention group were based on the care, comprised of routine clinical practice for pregnancy-
guidelines from ‘Exercise in Pregnancy’ by the Royal Col- related LBPP. Usual care is comprised of movement without
lege of Obstetricians and Gynaecologists (RCOG) and the straining herself in daily life, often forcing herself to rest,
guidelines from ‘Pregnancy and Exercise’ by Hacettepe Uni- taking paracetamol pills and consultation physical therapy
versity in Turkey (Reeder et al. 1997, Pillitteri 2007, Ak- clinic for LBPP. In the study, the doctor did not find it nec-
bayrak & Kaya 2008). It was emphasized that pregnant essary for the control group participants to be consulted to
women should complete their exercises as shown at least physical therapy clinic. None of the pregnant women in the
3 days a week for 30 minutes (Reeder et al. 1997, Pillitteri control group used paracetamol pills because they were
2007, Akbayrak & Kaya 2008). The duration of the exer- afraid of side effects on their baby. Nurse did not tell the
cise program was 4 weeks. Participants were offered a control group participants about not to exercise. If they
wanted to exercise they would do, there were no obstacle the research nurse explained the study’s purpose and proce-
for doing exercise. dures to the pregnant women in the control and interven-
The nurse spoke with the women in the control group on tion groups. The same procedure was repeated for all the
the phone once a week and asked them to assess their LBPP pregnant women. Blinding of participants was not feasible
and complete the data collection form. The final assess- due to the study design.
ments of the participants were made during a face-to-face
interview 4 weeks later (Figure 1). In the last assessment,
Primary outcomes
nurse asked to the control group participants ‘do you exer-
cise three times a week at least half an hour regularly?’ and The primary outcomes of this study were the change in
‘do you know anything about exercises for LBPP’. At the pain intensity at the end of 4 weeks compared with the
end of the study, the control group participants said that baseline and the changes in functional status at the end of
they did not exercise and they did not know the exercise weeks first and fourth.
for LBPP. Willing pregnant women in the control group
were advised on pain management strategies such as exer-
Data collection
cise program after completion of the 4 weeks of the study.
The nurse collected the data by meeting with the pregnant
women at the beginning and end of the study for a total of
Sample size and statistical power considerations
two interviews. The data collection form included the soci-
The sample size was calculated using the PS Software: Power odemographic characteristics of the pregnant women, their
and Sample Size program (http://biostat.mc.vanderbilt.edu/ pregnancy history and questions about any history of pain.
wiki/Main/PowerSampleSize). Using the literature, we calcu- In these meetings the nurse measured the severity of the LBPP
lated that a sample size of 48 pregnant women in both the and determined the functional status of the pregnant women.
exercise group and the control group (total 96 pregnant The participants measured the severity of LBPP at the end of
women) could allow for detection of a difference in VAS each week for a total of 4 measurements and recorded their
score of 10 mm between the intervention and control group, pain on a ‘Weekly Pain Follow-up Form’. Additionally, par-
given a SD of 15 mm with accompanying 095% confidence ticipants in the intervention group recorded their exercises
intervals (CI) and a power of 090 (Kalus et al. 2008). Ten on a ‘Daily Exercise Form’. The forms were collected for
mm difference in VAS score between the intervention and evaluation by the nurse at the completion of the study.
control group was accepted as meaningful based on Kalus
et al.’s (2008) study and our clinic obstetrician experience.
Measures
of pain by measuring the point the pregnant woman had groups, the Student’s t-test was used for values with a nor-
marked with a ruler. We examined the intensity of two mal distribution and the Mann–Whitney U-test was used
types of pain; perceived pain intensity at rest as VASrelaxation for values without a normal distribution. To investigate the
and perceived pain intensity during activity as VASactivity. differences within the groups, the paired samples t-test was
used for values with a normal distribution and the Wilco-
Validity and reliability of functional level xon test was used for values without a normal distribution.
The Oswestry Disability Index (ODI) was used to determine Repeated measurement results that did not have a normal
the participants’ functional status. The ODI was developed distribution were analysed using the Friedman Test. The
in 1976 by O’Brien (Fairbank & Pynsent 2000) and is a error level for all analysis was set at P = 005. The results
condition-specific outcome measure used in the manage- were analysed using SPSS, version 15.0 (SPSS Inc., Chicago,
ment of spinal disorders. The ODI has been broadly tested IL, USA). A nurse who was independent from the study
and was found to have good psychometric properties and evaluated and calculated VAS and ODI scores. All statisti-
to be useful in a wide variety of settings (Fairbank & Pyn- cal analysis was done with accompaniment of an epidemiol-
sent 2000). The ODI is the ‘gold standard’ for low back ogy expert.
functional outcome instruments (Fairbank & Pynsent
2000), is self-administered and consists of a 10-item ques-
Results
tionnaire. The first section evaluates the intensity of pain
and the others describe its disabling effects on typical daily
Study sample
activities including personal care activities (washing, dress-
ing), lifting, walking, sitting, standing, sleeping, social life We invited 209 women to participate, of whom 54 women
and travelling. Each item is scored from 0-5, with higher could not participate or declined to participate and 59
values demonstrating greater disability (Fairbank & Pynsent women were excluded for various reasons. A total of 96
2000). The ODI’s validity and reliability in the Turkish women were available for the baseline measurement and
population was examined by Yakut et al. (2004) and the were randomized. The flow of participants through the
Cronbach a value was reported as 091 (Yakut et al. 2004). study is shown in Figure 1.
The characteristics of participants analysed on an inten-
Exercise level tion-to-treat basis (n = 96) are shown in Table 1 (Montori
Exercise diaries are easy, cost-effective and frequently used & Guyatt 2001). At the beginning of the study, there was
methods to measure physical activity (Lindseth & Vari no statistically significant difference between the two
2005). In this study, exercise diaries were used to determine groups with regards to any of the possible confounding
the exercise levels of participants in the intervention group. variables (To & Wong 2003, Wang et al. 2004, Wu et al.
Exercise for 30 minutes at least 3 days a week was consid- 2004, Albert et al. 2006, Bjelland et al. 2011, Chang et al.
ered sufficient. 2012). The characteristics of the participants in the two
groups were similar at the beginning of the study. No
Ethical considerations baseline differences in Visual Analogue Scale during
An Academy Ethical Committee approved the study design, relaxation-VASrelaxation–1 score (z = 1355; P = 0176),
protocols and informed consent procedure with number Visual Analogue Scale during activity-VASactivity–1 score
1491-348-11/1539-227. Participants were informed about (z = 0018; P = 0985) and Oswestry Disability Index-ODI1
the study before inclusion and could decline to participate score (t = 0641; P = 0523) were observed between the
at any time. The participants read and signed the informed intervention group and the control group initially (Table 1).
consent form with the help of the nurse at the beginning of
the study.
The effects of the exercise program on pain intensity
and functional status
Data analysis
For the control group, the Visual Analogue Scale during
Based on the intention-to-treat principle, all pregnant relaxation (VASrelaxation–1) was 4277 (2657) at baseline
women were analysed according to the group they were and increased to 4902 (2489) VASrelaxation–2 at the final
assigned to, regardless of whether they received the inter- (z = 1271, P = 0204) and the baseline Visual Analogue
vention or not. To investigate the differences between the Scale during activity (VASactivity–1) was 5981 (2260) and
n % n % X† P
Parite
Nullipar 16 333 23 479 2787 0248
Primipar 17 354 16 333
Multipar 15 313 9 188
Family structure
Nuclear 46 958 44 917 0711 0390
Large 2 42 4 83
Education
≤8 years 11 229 5 104 270 0100
8 years< 37 771 43 896
Work situation
Worker 8 167 10 208 0274 0601
Non-worker 40 833 38 792
Perceived of economic situation
Inadequate 8 167 9 188 0071 0789
Adequate 40 833 39 812
Smoking
Non-smoker 34 708 32 666 0196 0906
Quit smoking in pregnancy 8 167 9 188
Smoker 6 125 7 146
Previous low back and pelvic pain story during pregnancy ‡(control n = 32, exercise n = 25)
Yes 13 406 12 480 0310 0578
No 19 594 13 520
Definition of low back and pelvic pain
Burning 5 104 3 62 0874 0832
Sharp 21 438 21 438
Blunt 4 83 3 62
Tingling 18 375 21 438
The time period that low back and pelvic pain was the most severe
Morning 2 42 4 84 4433 0218
Midday 11 229 11 229
End of day 11 229 18 375
Night 24 500 15 313
Table 1 (Continued).
Control (n = 48) Intervention (n = 48)
n % n % X† P
*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
*P < 005.
†
Wilcoxon test.
‡
Paired samples t-test.
at the end of the study VASactivity–2 was 6250 (2131) (z = 5090, P = 0001) scores (Table 3). The final mean
(z = 1132, P = 0258) (Table 2). ODI2 scores for the control group were significantly higher
For the intervention group, there was a statistically signif- than the mean ODI2 scores for the intervention group
icant difference in both the Visual Analogue Scale during (t = 3588, P = 0001) (Table 3).
relaxation (VASrelaxation) scores (z = 4347, P = 0001) and The weekly changes in pain intensity for control and
Visual Analogue Scale during activity (VASactivity) (z = intervention groups are shown in Table 4. We found a
4829, P = 0001) scores when compared with the baseline statistically significant increase from the first mean the
scores (Table 2). Visual Analogue Scale during relaxation (VASrelaxation)
For the control group, the baseline mean ODI1 score was score to the last mean VASrelaxation score in the control
3129 (704) and the final ODI2 score was 3196 (712) group (Fr = 20461, P = 0001). We also found a statisti-
(t = 0608, P = 0546). For the intervention group, the cally significant decrease in the mean VASrelaxation score
baseline the mean ODI1 score was 3225 (759) and the for the intervention group over the study duration
final ODI2 score was 2640 (803), with a statistically sig- (Fr = 58456, P = 0001) (Figure 3). The mean Visual Ana-
nificant difference between these two results (t = 4970, logue Scale during activity (VASactivity) scores for the con-
P = 0001) (Table 2). trol group remained at a similar level through the study
At the end of the study, there was a statistically signifi- duration (Fr = 4803, P = 0440). We found a statistically
cant difference between the control and intervention groups significant decrease in the mean Visual Analogue Scale
with regards to the Visual Analogue Scale during relaxation during activity (VASactivity) scores for the intervention
(VASrelaxation–2) (z = 3598, P = 0001) scores and the group over the study duration (Fr = 72507, P = 0001)
Visual Analogue Scale during activity (VASactivity–2) (Figure 4).
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) 4902 (2489) 0–100 2975 (2384) 0–88 3598† 0001*
VASactivity–2 (mm) 6250 (2131) 0–99 3540 (2357) 0–80 5090† 0001*
ODI2 3196 (7128) 21–47 2640 (8034) 11–44 3588† 0001*
*P < 005.
†
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)
First assessment 4277 (2657) 5044 (2692) 5981 (2260) 6071 (2253)
(0–100) (0–100) (10–100) (13–100)
1st week 3544 (2131) 5083 (2149) 6110 (19189 5783 (2190)
(0–81) (20–100) (10–100) (20–100)
2nd week 4079 (2429) 4458 (2353) 6019 (1908) 5054 (2504)
(0–86) (0–93) (20–100) (0–100)
3rd week 4173 (2600) 3765 (2355) 5650 (2386) 4112 (2518)
(0–89) (0–96) (0–90) (0–100)
4th week 4150 (2738) 3567 (2571) 5825 (2532) 4023 (2640)
(0–98) (0–95) (0–98) (0–91)
Last assessment 4902 (2489) 2975 (2384) 6250 (2131) 3540 (2357)
(0–100) (0–88) (0–99) (0–80)
F 20461 58456 4803 72507
P 0001* 0001* 0440 0001*
*P < 005.
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
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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 > 005). 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 > 005).
Chang H.Y., Jensen M.P., Yang Y.L., Lee C.N. & Lai Y.H. (2012)
Conflict of interest Risk factors of pregnancy-related lumbopelvic pain: a biopsy-
chosocial approach. Journal of Clinical Nursing 21, 1274–1283.
No conflict of interest has been declared by the authors.
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
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Dumas G.A., Leger A., Plamondon A., Charpentier K.M., Pinti A.
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& McGrath M. (2010) Fatigability of back extensor muscles
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adverse effects of standard treatment, acupuncture and stabilising
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Evenson K.R. & Bradley C.B. (2010) Beliefs about exercise and
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