Hi everyone, thank you for joining us today. My name is Dr. Sarah Huang and I am going to be the moderator for this session. We have a great group of speakers and I'm going to tell you a little bit about their presentations and a little bit about them. I unfortunately don't have the time to tell you all of the wonderful things that the speakers do but I'm going to give you just a brief overview of where they work and those types of things. So we're talking about musculoskeletal pain and pregnancy today. As I mentioned, I'm the moderator. I work at Shirley Ryan Ability Lab and Northwestern Feinberg School of Medicine. Our first speaker is going to be Dr. Kelly Scott and she's going to be discussing epidemiology of musculoskeletal pain and pregnancy. She is the medical director of the Comprehensive Pelvic Rehabilitation Program and a professor at UT Southwestern Medical Center. After Dr. Scott's talk will be Dr. Rupali Kumar who's going to be discussing biomechanics and gait changes during pregnancy. She is the associate director of the Comprehensive Pelvic Rehabilitation Program and an assistant professor of physical medicine and rehabilitation at UT Southwestern Medical Center. Next will be Dr. Jacqueline Bonder who's going to be talking about diagnosis and conservative treatment of musculoskeletal pain and pregnancy. She's the medical director of the Women's Health Rehabilitation and associate professor of clinical rehabilitation medicine at Weill Cornell Medical College. And finally, ending our session today will be Dr. Amit Nagpal who will be talking about when conservative care fails, interventional approaches to pregnancy-related and post-pregnancy-related musculoskeletal pain. He is the division chief of pain medicine and medical director of the UT Health San Antonio Pain Consultants Group. He's an associate professor in the Department of Anesthesiology at UT Health San Antonio. So I'm going to turn this over to Dr. Scott. Okay. Well, thanks for having me. And I am going to start us off by talking a little bit about epidemiology of musculoskeletal pain in pregnancy. And I have no disclosures. And so, you know, people who work in physiatry and have a focus on pregnancy and postpartum treat a lot of different things. And we don't have time during this session to touch on all of these things, but I'm just showing you there's a lot of different pathology that can be important to be able to recognize. And I just want to plug this textbook from 2015, which most of us authored some chapters on and it's a really great resource if you want to know more about this topic. So if we're looking at pain locations that patients report during pregnancy, this is one early study that looked at this. And what I think is interesting about this is that all of these with the arrows are actually lumbopelvic pain locations. And so in particular, the most common being lumbar, lumbosacral and sacral pain. And this is a more recent study with an N of 288. And they just asked patients to identify between three pain locations, upper back, lower back and pelvic girdle pain. And they showed patients these pictures. And so you can kind of see already, right, there's some overlap between low back and pelvic girdle, even in the pictures, but 94% of patients had pain in one of three regions. And then 92% actually had pain in either the lower back or the pelvic girdle regions. And you know, I think that if you're looking at studies, there's very no really, I would say studies that specifically try to differentiate low back from pelvic girdle pain in a way that is more than just a patient questionnaire. In other words, not like with the physical exam that I have seen, not a large scale study. And because of the overlap just between low back and pelvic girdle pain, you know, it's tough as a clinician, just looking at these studies to know exactly what they're talking about, because they do have different etiologies and treatments. I would say clinically, based on what I see, almost all patients with significant back pain in pregnancy, it is pelvic girdle pain, much more than either myofascial or spondylotic lower back pain. And so if you look at studies that look at one or the other or both of low back and pelvic girdle pain in pregnancy, this is a very common problem. And the epidemiology ranges in some large studies, anywhere from about 44% to 92% of patients. And then onset of back pain in pregnancy can be in any of the months of pregnancy, but most commonly, we're seeing that onset happening between months five through seven. But you can see from this slide, like a very significant percentage of patients get pain earlier. And then if you look at cumulative incidents of back pain, over time in pregnancy, again, you can see some starting early, and then you see a change in that curve from about 22 to 24, up to 28 weeks of pregnancy. So that's going to be the main time when, when most patients are presenting. A lot of studies have looked at risk factors for the development of low back pain and or pelvic girdle pain in pregnancy. And some of the risk factors that have been shown to be associated include pain prior to the first pregnancy, pain during a previous pregnancy, low back pain during menses, doing strenuous work or time, a lot of time spent standing, prior trauma to the pelvis, a greater age of the pregnant patient, greater parity, greater gestational age, a history of hypermobility like Ehlers-Danlos, or history of pelvic joint asymmetry, periods of amenorrhea, and a family history of pain in pregnancy. So what has not been associated as a risk factor? And I find this very interesting. Multiple studies have shown that patient height and weight, fitness level, amount of weight gained during pregnancy and fetal weight, none of these have an associated increase in risk. Now, there are a couple studies that seem to suggest that these might affect myofascial low back pain, but they do not seem to affect pelvic girdle pain development. And again, pelvic girdle pain is going to be our main back pain in pregnancy. So what else is not associated with increased risk? It's going to be prior epidural anesthesia, age at menarche, use of oral contraceptives, bone density, time interval since the last pregnancy, doing full-time work, and smoking history. So what happens to our patients when they get lower back or pelvic girdle pain? They usually look at what to expect when you're expecting, or they go talk to their obstetrician. And sadly, like both of these types of sources, most of the time will tell pregnant patients that the pain is coming from the uterus or the fetus pushing on the sciatic nerve. And they're often just told that the pain is normal, it's common, that nothing needs to be done about it, just live with it, it'll get better after pregnancy. And I think the prevailing view is really that there's no implications for the patient of not treating this. So I just wanted to go over in my remaining time, is that perception accurate? Should we be treating back pain in pregnancy, or should we just say, well, it happens to almost everybody, don't worry about it? So what are the implications of just living with it? So 25 to 50% of patients who have pain actually report their pain as severe, and they have lost time from their job and reduced social interactions. 8% of patients who have pain actually would classify with a severe disability during pregnancy. 49% of patients with pain are going to sleep less than half the night. And then only 15 to 30% of pregnant patients who do have pain report being treated for their pain. And 30% are using prescribed and non-prescribed pain medications during pregnancy, with some of those non-prescribed pain medications not necessarily being safe, like NSAIDs. And then what about long term? What about postpartum? Like, is this idea that, oh, the pain will just go away once you deliver, so we don't need to treat it now, right? Is that idea accurate? So 5% of all pregnant patients, not just of the subset who actually have back or pelvic girdle pain in pregnancy, were found to report pain three years later. 14 to 25% of patients with low back and pelvic girdle pain during pregnancy continue to have pain in the postpartum period. And if their pain is rated at moderate to severe during pregnancy, 68% of those patients continue to have pain after pregnancy. 7 to 10% of all patients with back or pelvic girdle pain in pregnancy have severe long term consequences, which affect function and quality of life that can last a decade or more. And 20% of patients with severe low back or pelvic girdle pain in pregnancy avoid a future pregnancy due to fear of recurrent pain, which is a horrible statistic, I think. I mean, all of these aren't great, but that is really sad. So thank you, and hopefully this talk will help us to understand how we can treat pelvic girdle and other pain in pregnancy. So next we're going to learn about physiologic changes of pregnancy that might dispose someone to develop back or pelvic girdle pain, and then we're going to talk about evaluation treatment of low back or pelvic girdle pain in pregnancy, both conservative and interventional. Thank you very much. Hello. Hi there. I'm Rupali Kumar, and I am going to be talking about biomechanics and gait changes during pregnancy. So thank you, Dr. Scott, for that excellent talk. I don't have any disclosures. And so today we're just going to go over the hormonal and physiological changes that happen during pregnancy, how those can start to affect the biomechanics during pregnancy, and how all of this leads to pain and changes in function and functional impairment. So you can think of the sequence of events as being initially there will be hormonal changes that occur, which then lead to biomechanical changes, which then lead to pain or changes in function, functional impairment. So as far as hormonal changes go, important hormones to talk about include estrogen, which is responsible for maturation of the uterine lining and enlargement of uterus and breast during pregnancy. This hormone affects bone, ligament, cartilage, and nervous system tissues. Additionally, there's progesterone, which is important for implantation and maintenance of pregnancy, affects breast changes, and also affects the same tissues, bones, ligaments, cartilage, and the nervous system. Studies have shown that in the third trimester, in patients who are pregnant and experience joint pain, the levels of estrogen and progesterone are higher. Another important hormone during pregnancy is relaxin. So this is a polypeptide hormone. It reaches its peak around week 12 and then drops off and plateaus, then declines right before delivery. This hormone has been shown to affect collagen, and specifically it decreases the density and organization of collagen, such that the ligament integrity becomes less, so the ligaments become more lax. Specifically looking at the pubic symphysis, relaxin reduces soft tissue tension, allowing for widening, which is important for delivery. As far as studies that have looked at an exact relationship between level of relaxin and pain, there is conflicting data, and most studies are kind of concluding that this is a multi-hormonal effect. It's not any one hormone that has the majority effect here. So here is a pregnant woman relaxin. So this is just a summary of all of the different hormones in pregnancy, and as you can see, how they affect all the different tissues, importantly causing laxity in ligaments. So all of these hormonal changes then lead to biomechanical changes. So in general, you'll see about 20 to 40 pound weight gain on average during pregnancy, with enlargement of breasts and uterus. So this leads to an anterior displacement of the center of mass, as you can see here. With that change, there's a magnification of the forces on the joints, and this is compounded by the fact that the passive restraints of the ligaments have become lax. So because of this, we get postural changes, functional impairment, and pain. So specifically going to go through different areas of the body. So looking at the thorax and abdomen, in the rib cage, we see expansion and the chest circumference increases by 10 to 15 centimeters. The subchondral angle increases, so as seen in this picture, the ribs are kind of pushed upward and outward. With increasing breast size, you see shortening of the pecs and stretching of the rhomboids. The diaphragm gets placed at a mechanical disadvantage, with kind of the large abdominal contents not allowing it to have full excursion. And then we see that rectus abdominis lengthens and separates, and we see rectus diastasis, and in that state, the function of the rectus abdominis is impaired. So this is a depiction of a rectus diastasis. The changes also affect all parts of the spine, so you see cervical kyphosis and forward protrusion of the head to allow for safe visual field, so being able to look over all of the increased body mass that's now in the front. Increased thoracic kyphosis, increased lumbar lordosis, which can be seen as a compensation for the center of mass shifting anteriorly, which goes along with also having anterior pelvic tilt and shortened paraspinal muscles as well. In the pelvis, we see at the pubic symphysis, there's widening that happens starting around 10 to 12 weeks, and in pregnancy, you expect to see up to 5 to 8 millimeters of widening, with the normal state being 3 to 5 millimeters, and in pregnancy, if the width becomes higher than 10 millimeters, then that's considered pathological. This is something that can be seen on x-ray, but it can also be seen pretty easily on ultrasound in your pregnant patients, and it's something that's resolved in the postpartum period usually. The sacroiliac joint, which is normally a very stable joint without much motion, starts to experience increased motion with the increased laxity, so this can result in pain and dysfunction in that area, and then the pelvic floor carries a pretty large burden during pregnancy, especially with all of the laxity of joints in the pelvis to retain the stability, the muscles often have to contract more, and we often see pelvic floor dysfunction with overactivity in this state. And then, of course, during labor and delivery, the pelvic floor muscles go through a lot in terms of extreme stretching, more than any other muscle in the body ever will go through. In the lower extremities, you see knee hyperextension, external rotation of the feet, foot pronation and loss of arch, which results in increased width and length of the foot, which is a change that often remains postpartum, and oftentimes the shoe size will change due to that. And then looking at how these biomechanical changes start to cause functional impairment, specifically with mobility, with trying to move from supine to sitting, with the weakening and stretching out of the abdominal muscles, it becomes difficult to get up from supine position in the way one normally would without putting too much stress on these already stressed abdominal muscles, so we really recommend that patients start to log roll in order to go from supine to sit. It also becomes difficult to go from sit to stand, requiring a lot of increased time to do that, and needing to have increased width between the feet for better medial lateral stability. Pregnant women tend to also have difficulty with asymmetric postures or movements. So, for example, getting dressed, standing on one leg at a time to put on pants, or getting out of the car or out of bed with stepping down on one leg than the other, these things often lead to a lot of pain because of the laxity of ligaments and allowing things to shift a lot more than they would in a normal state. So, we often recommend that pregnant women, you know, try to move both legs together and try to keep the pelvis neutral as much as possible to avoid that. Okay, and then as far as gait goes, you often see more of a waddling type of gait with a widened step width, again to increase that medial lateral stability and with lateral weight shifting from one side to the other. You start to see decreased stride length between second and third trimester, and you see prolonged stance phase and double support phases of gait and reduction in the gait velocity. Falls are fairly common in pregnant women, unfortunately. So, one in four pregnant women report falling, and the highest incidence would be between five and seven months. And a kind of alarming percentage of these are falls on stairs, so obviously very important to be cautious on the stairs when pregnant. And the incidence seems to drop during the third trimester, potentially related to just reduced activity levels at that time. And of course, these changes can lead to pain in various areas, so low back and pelvic girdle pain, as Dr. Scott was talking about earlier, are very, very common. And then in addition, there can be rib pain, abdominal, knee, calf, foot, wrist, carpal tunnel syndrome, and other nerve injuries. So, a huge variety of different types of musculoskeletal pains can occur in pregnancy, and we'll be going more into that in the next talk as well. As far as the postpartum period, studies show that the pelvic joints return to the pre-pregnancy state by around four to 12 weeks. And there are some studies showing that maybe in 75% of women, the pain results by three weeks and 89 by 12 weeks. But as Dr. Scott was saying, there is still a significant burden of people who have persistent pain or severe pain after in the postpartum period. And residual effects on the abdominal wall and pelvic floor are often seen, which can benefit from some of the conservative treatments and things that Dr. Bondar will be talking about next. So, here is my references including that book that Dr. Scott was talking about and thank you very much. Okay so hi everyone, thanks for for being here. It's great to see some familiar and not so familiar faces and names in the crowd. So I'm going to talk a little bit about some of the the conditions that were mentioned previously and already discussed in terms of how they develop and how common they are. And you know this question of is it really sciatica? We get told a lot or pregnant women get told a lot that they have sciatica or they've come into our office that it's sciatica but I think most of us here talking today would like to help kind of dispel that myth and talk a little bit beyond that concept. Let's see okay I have nothing to disclose. So I won't belabor some of this because we did discuss it already and some of it was reviewed but to kind of just go through some definitions so we all are on the same page. Low back pain kind of equaling pain in the lumbar region and so anything really above the ilium kind of thinking of that as more low back or lumbar and then thinking about pelvic girdle pain being more in the from the posterior superior superior iliac spine all the way into the groin and gluteal area but pain that never really goes past the thigh but usually stems and the etiology is somewhere within this box of of anatomy and anatomical structures. So I like to think about lumbopelvic pain as low back pain plus belt pelvic girdle pain and so most pregnancy related pain is often lumbopelvic or pelvic girdle and some sort of combination of the of the two. And so you know in talking to patients and talking to them about figuring out a diagnosis it's important to kind of recognize where their pain is. Is it in the anterior structures or is it in the posterior structures of the pelvic girdle or the low back? And so in talking about that I want to just bring up this concept that you know whatever can happen a couple of key principles that I'll talk about but one being whatever can happen in the non-pregnant state can happen in pregnancy and so just really kind of thinking a little outside the box that it's not always sciatica but you could have typical lumbar spine pathology lumbopelvic pain all these things that were already discussed but also that you can have things present that you wouldn't necessarily always attribute to pregnancy related. A CNS disorder, fractures, infections and even tumors can present in the pregnant as a cause of pain in pregnancy. And so again possible diagnosis this was kind of already touched upon in terms of how many different things we can see and there's even more than this so I won't go through them. And what I'm going to do now is go through a couple of case studies to highlight some of these these issues and kind of treatment of them and focusing more on the high yield and most common ones that we see. So in case number one this is a 27 year old woman who is a G1P0 meaning this is her first pregnancy. She presents at 24 weeks with left greater than right low back pain. It's also in the buttock and it does radiate into her left thigh. It increases with walking and prolonged standing as well as with these transitional movements again that was talked about earlier from Dr. Kumar in terms of you know these movements and functional movements that become very difficult to do in terms of sit to stands, rolling over from one side to the other, standing on one leg to put your pants on. She has no other medical history, no history of previous low back pain and her review of systems is pretty normal and negative for most things that we would be concerned of. So what's our goal here is really to differentiate between her description of the back pain and kind of is it more lumbopelvic or is it pelvic girdle. So her lumbar exam was pretty normal. She had no tenderness. It was a normal range of motion, no pain with range of motion. Her neurologic exam was consistent with some weakness but mostly due to pain with knee extension and hip flexion but otherwise it was within normal limits and the remainder of her musculoskeletal overview exam was normal and then we perform a couple of special tests that I'm going to go through in terms of helping to diagnose some of these issues. So our greatest tool in pregnancy since we can't usually do too many imaging studies or we reserve imaging studies for those that are not getting better and I'll talk a little bit more about that is the physical exam and so this force favor maneuver which is an SI provocation, a sacroiliac joint provocation maneuver becomes important and basically you know it can be done to assess for hip pathology but for the pregnant women we also use it for SI joint or pubic symphysis pathology and so you know a positive test is pain in the ipsilateral SI joint or pubic symphysis. So if you know if putting pressure on the knee and the ASIS pain in the SI joint would be a positive test. Another test for SI joint pain would be the posterior pelvic provocation test or we often call it the P4 and this is where you put posterior force through the femur in a flexed hip and knee to test for gluteal region or SI joint pain and so if that's positive again is also considered positive for a sacroiliac joint pain and these pictures of me performing it on a test are also from that book that everyone's talked about already so it's a great resource. The functional straight leg, the functional testing we often will do something called the active straight leg raise and that's pictured here where you basically have the patient lying in supine and you can elevate the head of the bed a little bit if a patient's too uncomfortable lying on their back. We have them raise their leg just a little bit off the table ask them if there's any pain and then give them compression to the anterior superior iliac spine and if it feels easier or is less painful with that compression that's considered a positive test and this has been shown there's a group of authors that have shown this many times to be a pretty sensitive and very specific test for sacroiliac joint pain and for a functional movement. I'll talk a little bit more in terms of treatment how this may help us. So she was given a diagnosis of pelvic girdle pain due to sacroiliac joint dysfunction and so again based on the exam thinking about the pain that it did not pass her knee this is key in determining whether or not this is kind of quote true sciatica and recognizing that true sciatica would really go past her knee and go into the foot but because hers her pain did not we really know that it's not true sciatica. So I'm going to just a little bit in terms of treatment and talking about what's happening at the SI joint but and this goes back to some of the biomechanical changes that happen about the motion at the SI joint that changes during pregnancy and so that the intrinsic properties of the joint that provide stability are normally compromised as is some of the more external components of the components muscular structures and anatomical structures that kind of help withstand force of the SI joint and kind of usually help it stay stable again may also be compromised and so the force closure which is really more the muscles and the ligaments we know the ligaments are more lax and loose and so we rely more on the muscles to kind of help stabilize the joint and that's where motor control of the joint comes in in terms of treatment and wanting to focus on sequencing and teaching strengthening of the muscles to kind of use them more actively and then of course there's the emotional aspect of pain but I'm not going to kind of delve into that but that can also sometimes play a role in sacroiliac joint pain and pregnancy and so ultimately like I said this pain occurs because of diminished power in the muscles and some increased laxity of the ligaments and then improper firing of the muscles which becomes important for treatment and so the other part of treatment that we you know talk about is the is strengthening the core muscles again I'm not going to go too much into all the different exercises that one could do but just know that we do really want to make sure that we strengthen the core the core muscles and kind of encourage patients to realize that strengthening the core muscles is safe and okay to do in pregnancy because many are under the impression that it's not and so again just kind of highlighting some of the the muscles to strengthen and so what do we do right then in the office when a patient's complaining of pain is we can educate them kind of teach them a difference between sciatica and sacroiliac joint pain or what might be going on and why it's happening and then also I like to teach patients how to contract the transverse abdominis with simple exercises in the office so that they can start practicing that on their own at home to help movements be a little bit more easier we we talked about simple bio we talk about simple biomechanics and things that we can change to make their daily function a little bit easier in terms of they're working at a desk maybe some over-the-counter orthotics for their feet to kind of we're making sure they're wearing good shoe wear often recommend a stability belt and I'll go a little bit more into that again proper footwear and then starting physical therapy so what are our goals with that in pregnancy to treat these women is we want to make them not have to watch the clock and try to make it easier for them to get through and so we address all of these issues the biomechanics right like we would uh non-pregnant women with the biomechanical factors the motor control education ergonomics how to take if they have children at home already how to help how to take care of those children and with better ergonomics and discuss some functional mobility with them so to treat the sacroiliac joint it usually consists of muscle energy techniques and the physical therapist working with patients on that they will often do some soft tissue mobilization as well to kind of help treat the the tight muscle and the myofascial pain that might go along with this stretching of some of the uh more lower extremity muscles to kind of help then strengthen them and make them more efficient in in their strength and again uh functioning strengthening sorry their their trunk and pelvic stabilization muscles uh both their core and their pelvic floor muscles and then a support belt and often this is uh very very helpful for women you know there's some people might argue that just giving them this is all they really need um but I'd like to think that doing this combined with some exercise would is really is really key and so um uh Dr. Fitzgerald who's the mentor for a lot of us giving this talk today um published a study in PM&R back in March about uh you know second and third trimester pelvic girdle pain and it was an observational study of 63 women who wore this belt which is called the cirolla belt for four weeks and it showed reduced pain and improved function at that four-week mark in that active straight leg raise test so patients who were able who wore the belt for four weeks had improved symptoms when they were re-examined in terms of the active straight leg raise and had less pain. Another study that talked about the treatments of lumbopelvic pain and this wasn't necessarily specific to sacroiliac joint looked at many many studies they examined 58 studies and that included all of these treatments and basically the strongest evidence interestingly enough was for acupuncture and pelvic belts so like I said these pelvic belts some people may argue that it's all you need to do um but you know we we strongly encourage the exercise as well because we do see that that it's very helpful from a clinical standpoint and so the limitations of the study was that they really didn't differentiate between the type of lumbopelvic pain that these patients had so this patient just to kind of go through and speed up a little bit but these patients this patient basically went on to get worse she develops neurologic symptoms and sensory deficits I encouraged uh an MRI at that point to kind of get a better sense of what was going on and the patient and the OB were both hesitant but this just brings up another point in terms of when should we be concerned and when should we send these patients for imaging so if the pain is disabling and really getting to the point where it's interfering with their function in their daily life if they cannot wait there on a leg implying that maybe there's some sort of fracture if they develop any neurologic symptoms that seem unexplained by any other symptoms or any other findings progressive nighttime pain which is common in pregnancy and then worsening pain despite getting rehab and and if there's an unclear diagnosis so in this patient it was it was unclear was there something new going on or was this just her typical sacroiliac joint pain it didn't make sense that she was having neurologic symptoms eventually after she delivered she did obtain an MRI uh and it was similar to this one this is not hers but it was similar and she did actually have um bilateral sacral insufficiency fractures and most of these are are not reported until after pregnancy probably because of the underutilization of imaging and so I just kind of encourage the one to bring home the point that it that that you know using imaging can be necessary to kind of help treat some of these patients so uh how to treat those insufficiency fractures basically you treat them like a stress fracture and offload them give them maybe some cool therapy weight bearing as tolerated crutches walkers or some other assistive device um and I don't want to belabor that because I talk a little bit more about it as I go further and I want to make sure I get to the next case which is basically a similar woman she's 30 in her first pregnancy 36 weeks uh her pain started in about the 29th week of her pregnancy at the pubic synthesis and it's now worse she has pain with weight bearing again rolling in bed and it's also tender to palpation she has associated groin pain with it and um mostly on the right side she has mild low back pain as well and she has a history of hypermobility so good again kind of going back to those risk factors that she was hypermobile to begin with her exam was pretty normal but again just to kind of highlight these special tests to diagnose pubic synthesis dysfunction or pubic synthesis pain we often palpate the pubic synthesis and and pain lasting than greater than five seconds when you removed remove your hand is considered uh positive also a single leg stance or sometimes called modified trendelenburg is not really to look for for weakness but more to see if when they're standing on one leg they have pain in that pubic synthesis or the groin area and that's considered a positive test for pubic synthesis pain these patients also can have pain if you ask them to do hip flexion um with uh in supine and pain when you ask them to do resisted adduction on manual muscle testing and so just quickly because there's probably some you know thoughts about whether or not what's the difference between uh um pubic synthesis dysfunction and pubic synthesis diastasis and this is basically a quick summary but you know thinking about the difference is is that usually dysfunction um you know is a little bit maybe a little bit less um pain they may be a little bit more functional than patients with true diastasis who might have more of a an inability to walk or waddle and gate sometimes you can press on the pubic synthesis and actually uh feel a gap and then these patients also um also often have more radiating pain down into their legs or go back if there's a separation and so just quickly um to talk about some imaging and the recommendations these are the ACOG guidelines from the earlier this year but that basically you know that show and basically say that ultrasound and MRI show no associated risk um and but they are only to be used to when an answer is needed and relevant clinically to really help guide treatment um you know x-ray ct and nuclear medicine are really not uh suggested but you know there are exceptions when it is necessary and when you have to kind of pose whether or not exposure to the fetus out you know outweighs uh the benefits of waiting and then contrast it really should be limited as well so the management of this patient is pretty similar to the si joint patient so i won't belabor it so we to in order to get to our last speaker but basically just thinking about offloading maybe some pool therapy and bracing as well these patients do benefit from bracing too but uh you know sometimes they also can't tolerate that sacroiliac joint belt and do better with more of a belt that kind of offloads the belly and kind of holds up uh the belly a little bit off the pubic bone and so just real quick in terms of postpartum this patient is now eight weeks postpartum um she had a forceps delivery delivery and this is much more common situation for actually developing diastasis of the pubic symphysis and so you can see here um that big gap which is definitely more than 10 millimeters this one for sure is even bigger um and then i just want to highlight that these are what we call flamingo views where basically you have you can see here it says right leg hanging or left leg hanging that basically can often tell us about instability of of the pubic symphysis and can help kind of figure out management as well and so uh again i'm not going to go through the the epidemiology of this but but it does happen it's not rare um and the treatment basically is is is pt a belt you want to make sure and i'll just highlight the most important part of this i i think in telling patients and obese is to initiate ibuprofen or um anti-inflammatories to help decrease the long-term risks of degenerative changes in the pubic symphysis there are studies that show it does help prevent osteitis pubis in the pubic symphysis so we often get asked how these patients should deliver um when they are have when they do have pain and the answer again is basically it's actually safer to have them have a vaginal delivery than to go on to have a c-section there's no recommendation to really have a c-section because we know that those patients might still develop pain or have other complications that out that don't outweigh a vaginal delivery and so lastly the last case basically a you know similar patient but she's a little bit further in her pregnancy she starts that pain with weight bearing um she's a little bit older and she basically um is on she's had a dbt prior to pregnancy and she's on an aspirin and she now has developing pain in bilateral groins you know one side is worse than the other she's only better with sitting and on her physical exam she has similar findings but she's really unable to put any weight on one leg and she really cannot stand on her right leg because of the pain she does have all these other positive tests and our biggest concern here is for something called transient osteoporosis of pregnancy which is when patients develop um often the often finding that we see in transient osteoporosis of pregnancy are these uh subchondral fractures in the femur and so basically this is a contraindication to uh a vaginal delivery because there are studies that show that patients will go on to have worsening fractures and require stabilization surgery if they do deliver vaginally and I won't go through the mechanism of how it develops or the pathophysiology of it but basically it the the tissue there's tissue ischemia ischemia and you see marrow edema of the bone and these are the patients that really do need an MRI um and like so as I said earlier if patients are developing pain to the point where they can't wait there it really becomes important sometimes to find these uh fractures and make sure we know how they should deliver and so this is just some of that the data and the evidence I can happy to share the references but again for the sake of time I will hold off um and then like I said c-section and those are my references and I apologize for my email going off that's it I'm going to stop sharing and thank you for listening good morning everybody thank you for joining us on this uh awesome Saturday morning of our second annual virtual AAPMNR annual assembly. I'm Amit Nagpal, I'm the division chief of pain medicine at UTHealth San Antonio. I'll be discussing today uh after all of my amazing colleagues talked about the epidemiology and biomechanics and and conservative treatment of pregnancy-related musculoskeletal pain how we treat that these conditions in the event that conservative treatment were to fail. I have no relevant disclosures to this talk um I'm going to call the, I use the word reasonable for these injections for pain during pregnancy and or post-pregnancy. I think reasonable for post-pregnancy for sure is, are any of these, if patients have consequent and result in continued pain after pregnancy, but, uh, during pregnancy, maybe I shouldn't have used the word reasonable, but I I've, I've done all of these injections during pregnancy, but I always do it with a little I call these, um, these types of procedures, STPs or sphincter tightening procedures, because I'm always a little nervous to put a needle into a pregnant patient for various reasons. But the main reason is a question that I always ask myself before I do an injection on a patient who is pregnant is, which is very rare. I want to point that out. I'm not one of these people who's going around putting needles in people who are pregnant all the time, but, uh, can you put somebody into preterm labor doing one of these procedures? And the answer has to be, maybe, because we just don't know the traditional teaching has been for a long time that you can, but the data on that is not good enough to say that it's true or false. Um, I have not myself, knock on wood, ever put somebody into preterm labor doing a procedure. Uh, but, you know, maybe one day I will, or if there is a preterm labor within 24 or 48 hours of a procedure, it would be difficult to determine or to decide that it wasn't due to the procedure that you did. So, uh, SI joint pain has been talked about a lot in the, in the last, uh, 45 minutes. I will, um, very quickly go through that just, but, you know, pain below the PSIS. And although there are plenty of provocative maneuvers and, uh, Dr. Bonder, uh, gave us a one that has pretty good sensitivity and specificity. We just don't know how valid any of these physical exam maneuvers are for SI joint pain and certainly not in a pregnant patient. We don't, uh, physical exam for SI joint pain is notoriously difficult. And so part of that problem is because oftentimes the pain is due to dysfunction, uh, not necessarily arthritis and certainly in a pregnant patient, it's usually due to ligamentous laxity. We also know, know, and, uh, in our, in the interventional pain literature, we've renamed sacred iliac joint pain to be posterior sacred iliac complex pain, because the true pain generator may very well be one of the, uh, the posterior sacral longitudinal ligaments, as opposed to the SI joint itself. The SI joint gets the majority of its innervation from the anterior component of the joint. And so denervation procedures that a lot of, um, us do then in a non, in a non-pregnant patient are done in the posterior portion of the SI joint. And therefore it's not truly denervating the SI joint. A lot of these physical exam maneuvers were discussed, so I will not go through them in total, but, but I'll, I will say that it has become a problem with, uh, insurance companies that if I don't have at least three of these next five, uh, physical exam maneuvers positive, then I can't get an SI joint paid injection paid for in the vast majority of my patients. The study that showed that you have a tremendously increased, uh, likelihood of the SI joint being the source of pain in a patient when three of these five maneuvers is positive has a lot of, um, uh, uh, sources of bias within the study. And we also don't know necessarily that the, that there's isn't, there's not a ton of false negatives when we miss some of these people when they don't have all of these physical exam maneuvers positive. So distraction is one of them. Iliac thrust is another one. Uh, and my slides are available and I'm happy to answer questions about any particular one of these. The Faber test I heard Dr. Bonder speaking about a little bit as well. You know, the classic description of the Faber test originally, as it's described, is that the pain is actually on the contralateral side of the SI joint, even though it's, let's say it's on this, uh, in this model here, the, um, it's the right, uh, hip that's being flexed, abducted, and externally rotated. It's actually the left side that would be painful in, uh, in a positive Faber-Patrick's test classically described. Although the more mod, more recently people have said it's a lateral. The Iliac compression test, uh, and then Gaines's test. So if three of these five are positive, at least your insurance company might pay for you to do an SI joint injection. The test that has the most, uh, classically described again, uh, until recently, uh, physical exam maneuver sensitivity and specificity to is the Fortin finger test, which is just if the pain of the patient points themselves to their area of maximal pain at or below the PSIS, if they do that, then that's considered a positive Fortin finger. And that's probably the best guess we have, but truly the only way we can be a hundred percent sure, uh, is serial diagnostic blockade, which we can't often do on a pregnant patient. Cause it's probably not the correct way to do it. There's all these other tests, right? There's Yeoman's test. And then there's the classic SI joint injections is how I've done SI joint injections for years and years under fluoroscopy. Uh, there are some questions already in the chat that I noticed about, uh, x-rays in pregnancy, and we'll get to those questions. Uh, but I would not put a patient under fluoroscopy to do an SI joint injection who's pregnant. It was a bad idea. The radiation is almost exclusively targeted towards the pelvis. Um, there's no reason we have to do that because these days we can do this under ultrasound guidance. We can clearly visualize the ileum and the sacrum. Uh, I had a pregnant patient who had bilateral SI joint injections on in the early portion of her third trimester in a sideline position. It was difficult. It can be done. You of course, can't put that patient in a prone position like ordinarily would, but, um, her pain was so incapacitating from her sacroiliac joints that she was unable to care for her existing children. And, uh, she, she sort of begged for this and, and I did it and she had a hundred percent relief for the duration of her pregnancy. So I felt really good about it. I felt really, uh, like it was the right decision, but I was scared. And I, and, you know, I probably done 10 of these in my career, about one a year on a pregnant patient, but it's all, this is the most common. This is the most common of the injections that I on a pregnant patient, because if they failed, uh, this SI joint belt and the exercise programs that have been discussed, then that might be the next step I take. Uh, while moving to myofascial pain next, there is a difference between a trigger point and a tender point. This is of utmost importance. No more important can it be than in a pregnant patient, because there is no data to support the fact that a tender point will improve with an injection, but trigger points will. And so if you don't know that as a trigger point, you should absolutely not be injecting it, especially in a patient who's pregnant. And the definition of a trigger point is that it must have these five characteristics. It has to have a tender area muscle with a predictable location, with a top band of myofascial tissue, with a characteristic referral pattern. And in that patient, how patient of that tender area muscle reproduces the patient's pain. If it doesn't have all five, then it's not a trigger point. And you ought to think twice about whether you should be injecting it. These, uh, trigger points, of course, were classically originally described by Janet Trevelle and, and Simons. Trevelle was, uh, JFK's personal physician. Uh, I don't have time to go into that history, but it's a fascinating history. She's probably one of our, she was a physiatrist without being a physiatrist. She was a family medicine physician and, and, uh, uh, leading, uh, physician of her time. So she, um, the definition at the time that Trevelle and Simons made of, of a myofascial point has changed. And so we don't use her definition anymore, but note that at a point in, in medical, uh, history, a trigger point was also defined as having motor dysfunction and autonomic phenomena. So, and I do see this more in pregnant women than I do in patients who aren't pregnant, especially the autonomic phenomena. I see a lot of abnormal sweating over trigger point areas in pregnant women, more so than non-pregnant, uh, patients. Now there's a recent, uh, consensus Delphi study to try to come up with a better, um, definition than the American College of Rheumatology has for a trigger point. And there, the first round of this Delphi study stated that the truth, there are only three necessary items for a trigger point, a top band, a hypersensitive spot and referred pain. So, um, the second round, they agreed again. And lastly, in the third round, they sorted the 45% of them said, maybe there's such a thing as a latent trigger point, which doesn't include referred pain. So you may see these definitions when people discuss trigger points rather than the ACR definitions. But if you have somebody with a so-called latent trigger point, then I would encourage, um, I would encourage you to think twice again about whether you should be doing an injection in that area, because a latent trigger point, whatever that is, I'm not exactly sure I know what that is, but it probably may not improve with a trigger point injection. Now, the problem with trigger points is they're often, uh, commonly misdiagnosed as radiculopathy. The last thing I would like to do in a pregnant patient is to put them under fluoroscopy, which is the only safe way to do, to do an epidural steroid injection and do an epidural steroid injection. I have no interest in that. Every conservative treatment, uh, I can think of is more important than sticking, uh, doing something in the epidural space on a pregnant woman. I just, I can't fathom, uh, that it would be reasonable. There's all kinds of other ways to treat radiculopathy in pregnancy. Uh, there is a common, uh, old misconception that, uh, our faculty had a long email discussion about in our email thread before we put our lectures together about the fact that the most common cause of lumbosacral radiculopathy in pregnancy is that the gravid uterus is, uh, placing pressure on the lumbosacral plexus. That's even a pain board exam question most, uh, most years. Uh, and I just, I, I think that disc herniation is more common, but what's really, really uncommon altogether is radiculopathy in pregnant women. It's, it's very rare. And so much more common is a trigger point caught and look at the classic distribution, for example, of the infraspinatus and the scalenes, it looks like a C6 radic. And so most of these women really have a trigger point that can be managed conservatively first, but a trigger point injection isn't crazy. And even, you know, piriformis, a trigger point or hamstrings, these all kind of look like S1 radiculopathy or maybe SI joint pain. And we have to be really cautious about the way we, as physiatrists, who should be the leading, uh, physicians who treat these types of things, uh, are defining and diagnosing them. Now, trigger point injections have been shown to be superior to placebo, but, um, that's a tough to do a placebo essentially is that the needle is taped to the skin because truth be told, there's no difference between dry needling and needling with local anesthetic or steroids or local plus steroids or anything. So I only use local anesthetic in my trigger point injections so that the area is numb so that I could perform some dry needling. I do it under ultrasound, um, in all cases. And I don't think there's, there's a lot of people out there with steroids. Some people put Ketorolac in their trigger points. None of that has any advantage and all of it carries risk. The most commonly performed maneuver to diagnose piriformis syndrome, which is piriformis is a trigger point that I'll talk about very specifically because it's so unique because sometimes the sciatic nerve gets entrapped, uh, within the piriformis muscle or above or below it. And, uh, so flexion, adduction and internal rotation and no good validation study for this actually exists to see whether that really does, um, reproduce pain and cause piriformis. Now there are good studies for physical exam for the, these two studies, these two, uh, maneuvers, the active piriformis stretch, which is resisted abduction and external rotation of the hip, which is shown in this picture. This is me doing this to one of my old fellows. And then the seated piriformis stretch, which is where the patient's seated, the hip and knee extended, the limb is internally rotated. My hand is in the wrong place here. My left hand should be in the sciatic notch. I'm sorry, the, um, the sciatic, uh, notch in the, uh, in the, in the buttock area, not in the, uh, in the knee and a positive test again is reproduction of the symptoms. If you have both of these positive, it has a huge likelihood ratio. And this was used against the goal. Whenever you think of sensitivity and specificity, you have to think about the gold standard that it was compared to. These were compared to endoscopically, uh, looking at men and women who had piriformis syndrome, uh, symptoms and whether or not the sciatic nerve was entrapped inside of the piriformis. That's the best diagnostic standard we could use. And this is really, really good. So for diagnosing piriformis, we ought to be using these two physical exam maneuvers and seeing if they're both positive together. And that's sensitivity and specificity is listed here. Remember that the piriformis originates on the anterior border of the sacrum and inserts on the greater trochanter. It's a very deep muscle. So it's difficult to palpate. Even those of us who think we can palpate it probably can't. Uh, we talked about some conservative treatment, but ultimately the thing about the piriformis muscle, that's different than other trigger point injection trigger points. If you have a piriformis trigger point, then you would still go ahead and use local anesthetic. But if there's piriformis syndrome types, uh, findings like sciatic irritation, you may consider adding a steroid. And there is some, uh, moderate data that Botox botulinum toxin, I should say in the area, uh, is, uh, is beneficial, uh, as compared to other trigger points, which have been shown to not be, uh, have any further benefit with botulinum toxin as compared to local anesthetic. Yes, you could do these under fluoro. I haven't done under one under fluoro in eight or nine years. I almost, I always do them under ultrasound. There are, um, ultrasound guided techniques, many that have been described, all kinds of different ones, but ultimately remember that the sciatic nerve is right there. So you could accidentally block the sciatic nerve during that procedure. Carpal tunnel injections under, um, uh, ultrasound or, or, or blind are very reasonable, uh, with, uh, patients who are pregnant because of the swelling that occurs in the transverse carpal ligament that causes, uh, compression that can cause compression of the median nerve. Um, the test with the most, the highest sensitivity and specificity is probably Durkin's test, which is holding pressure over the carpal tunnel, as opposed to tapping it, which is to Nell's test valence test, which is flexed risks opposed to each other, uh, also can be positive. And there's all sorts of different studies as to which are most sensitive, most specific, but classically we think of Durkin as being the best. This is an image of a median nerve that's being injected under ultrasound. The needle is here that remember there's a nine tendons inside of the carpal tunnel, the four cut tendons of the flexor. Well, I'm going to skip through that and move on because we're running out of time. So last, uh, disorder I'm going to talk about is a athletic pubalgia, which is not what these women are going through, right? But it's, it's the same vicinity, which is a sports hernia vicinity is pubic symphysis pain, but it's not due to anything related to, um, uh, what we classically think of as sports hernia, but more of dysfunction of that tendon due to ligamentous laxity again, or most of the time. And this has been discussed already today, but there are ultrasound guided, um, uh, in, uh, symphysis pubis injections that are described as early as 2010 in pregnant women, uh, with reasonable success. But these are case studies. These aren't any, they aren't even case series. So we don't really know how well they work in a pregnant patient. Uh, and lastly, myralgia parasitica, which is a diagnosis that we are all familiar with. It's a symptoms and including pain, numbness, and or paresthesias of the lateral thigh and the distribution of the lateral femoral cutaneous nerve. This can easily, easily, easily be blocked under ultrasound at the level of the ASIS in between the tensor fascia latae and sartorius muscle. It can be visualized. It looks like it's inside of a hammock every single time, right underneath the subcutaneous region. Um, I thought, I guess I have a few more. So trochanteric bursa pain is, uh, something that classically occurs to this population, but we don't ever know what the real cause is because there's so many muscles that originate or insert near the GT. They're all listed here. There's so many bursa here. It could be an overlying L5 or DIC in, in some patients. So you just don't know where it is, but ultimately I try to find the place, the source of maximal tenderness. If I'm going to do an injection here and then inject in that area again with ultrasound. So, um, if you have any questions, uh, please, uh, ask, we'll try to go through some right now. Thank you all for your time. And we appreciate everybody being here. Hey guys, I'm afraid we are going to get cut off here. Um, we tried to answer a couple of questions in the chat. Um, let me go up and see here. Um, x-ray and pregnancy was one of the questions. I generally don't order x-ray and pregnancy. Any of the other, um, members of the panel want to discuss that? The American College of Obstetrics and Gynecology has some, uh, verbiage in a, in a consensus statement about the maximum amount of radiation that a woman should undergo in various trimesters. I would recommend that if someone is considering ordering an x-ray that they consult with the OBGYN of the patient who is pregnant to look at that, um, that, uh, statement and make sure that everybody understands how much is, uh, accessible and available and is reasonable. But usually you try to conserve those for emergencies. Yeah. Go ahead. I would also just say on the x-ray, I don't think it really adds anything. I mean, doing it during pregnancy is not going to really change your treatment if you're looking for people, like depending on what you're looking for. Um, it probably won't add very much. There was another question about, um, what percentage of patients with pain in pregnancy, um, go on to develop chronic pain? So, um, I think the literature shows, um, you know, about 10% and, uh, seven to 10%. And then, and I'd say I see that in my patients as well, about 25% continue to have pain in the postpartum period, but then maybe seven to 10% chronic pain. Um, another question, how long would you recommend offloading for pubic symphysis dysfunction? Yeah. So I typed that in the chat. I basically said, I usually use pain as my guide for the patient. Um, you know, initially if it's postpartum and it's a true pubic symphysis diastasis and separation, I limit them basically, I'm in New York city. So I'd basically limit them to their apartment for about two weeks, um, and use NSAIDs aggressively and then have them follow up and kind of slowly, uh, basically don't often, you know, they can walk around their apartment, but I don't have them walk more than that. And basically do it based on pain symptoms as they start to improve, uh, we'll let them kind of start to walk slowly a little bit more. Um, how about trigger point injections using saline in a pregnant patient? Uh, there's no reason if you're going to do a trigger point injection, there's no reason you have to use saline versus local anesthetic. They carry the same risk and, uh, saline is painful. And, uh, when you inject it and a local anesthetic is not, so I prefer look now let's, I mean, local anesthetic is diluted in saline, right? So it's just saline with a couple of molecules of bupivacaine in it. So I really, um, prefer a lot, a lot of cane, but there's no reason, uh, you can't. And your thyroid pain is lidocaine. Um, with the, we don't have pregnancy classes of medications anymore, but in the prior pregnancy class, it was rated the same as Tylenol pregnancy class B. So consider it safe. What are your thoughts of perineural injections using D5W? Um, so dextrose is neurolytic, mildly neurolytic, and when it's injected perineurally, the idea is that you're mildly neuralizing those nerves. Um, so it's a, it's, it's, it's a controversy as to people talking about whether that is truly prolotherapy or if it's a neurolysis type of procedure. Uh, I'm not familiar with any, uh, and I'm thinking about specifically where we use them most commonly would be the posterior sacral longitudinal ligaments. And I'm not familiar with any data in pregnant patients as to whether that's because there's such you, there's so few studies on actually doing anything procedural on patients in this, um, era in this venue. So I just don't think that there's data on that right now. I haven't personally tried that for that reason. Um, I saw Dr. Bordstein gave a comment about using prolotherapy in these patients. I don't know why that never crossed my mind. It's, I should be doing that. It just, I use steroids and I should stop. I should do prolotherapy. It makes a lot more sense. Um, I just want to add with, with any thought of intervention in pregnancy, just, um, remember as well, like pregnant patients are very litiginous, right? And so, um, I think like Dr. Nagpal was saying, you do want to think, well, could my procedure cause preterm labor, but even if it couldn't just be very cautious, like even if you're doing anything that's not anywhere near the belly or the pelvis, um, you, you could get, get blamed for something. So, you know, risks need to really, um, and benefits really need to be weighed. All right, guys, I think our time is up. Um, thank you all for joining us. And I think most of us put our emails in the chat. So if you have further questions, feel free to reach out, have a great rest of, um, annual assembly.

musculoskeletal pain

pregnancy

treatment

panel discussion

back pain

pelvic girdle pain

physical therapy

interventional approaches

diagnosis

multidisciplinary approach