Author’s name and year
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Description of community-based non-pharmacological interventions
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Description of control group interventions and duration
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Elden et al., 2008
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Standard treatment plus acupuncture for 8 weeks. Eight or nine tender acupuncture points and one or two trigger points were selected individually in the same segments as the location of pelvic girdle pain after diagnostic palpation to identify sensitive spots. Two acupuncture points on the medial side of the leg and foot were selected in the same segment as the pelvic girdle pain. The aim with the stimulation was to activate both segmental and central
control systems. In addition, two points on the hands and head were chosen, extrasegmentally to the pelvic girdle pain, to strengthen and lengthen the effect on the central control systems. All participants received 12 acupuncture treatments, each of 30-minute duration, twice a week for 4 weeks and once a week for 4 weeks.
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Standard treatment plus non-penetrating sham acupuncture for 8 weeks. Standard treatment included general information about the condition and anatomy of the back and pelvis and a pelvic belt. The women received adequate advice and home programme exercises designed to increase strength in the abdominal and gluteal muscles, and information was supplemented by a leaflet. The women were also instructed to avoid other treatments during the intervention period. The sham acupuncture followed the same protocol as the real acupuncture.
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Lund et al., 2006
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Ten acupuncture treatments each of 30 min were given twice weekly over five weeks by a registered physiotherapist, well experienced in acupuncture, with a regular clinical practice. For each treatment session, 10 classical acupuncture points were selected for stimulation and chosen depending on the site of pain (BL 27, 28, 29, 31, 32, 54, KI 11, CV 3) in combination with more peripheral points (SP 6, LR 2, LI 4), intra- or extrasegmental related to the neurological innervations of the painful area. Usually, three to four of the BL points were used and applied bilaterally. Two types of sterilized steel acupuncture needles were used for acupuncture stimulation: 15 mm length/0.20 mm diameter (Seirin) and 30 mm length/0.30 mm diameter (Marco Polo, Schwa Medico).
For the deep stimulation, the longer/thicker needles were used and inserted intramuscularly into the depth according to the acupuncture manual. The needles were stimulated five times during the treatment sessions by manually twirling the needles 180 degrees back and forth until the patients reported sensations of numbness, heaviness, and warmth, described as de qi in Chinese traditional medicine. During the treatment, the patients lay on their sides and for optimal comfort were supplied with pillows.
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Two types of sterilized steel acupuncture needles were used for acupuncture stimulation: 15 mm length/0.20 mm diameter (Seirin) and 30 mm length/0.30 mm diameter (Marco Polo, Schwa Medico).
During the superficial stimulation the shorter/thinner needles were inserted subcutaneously over the acupuncture points and left in place until the end of the treatment. To mimic the procedure of deep stimulation, the therapist sat down by the patient four additional times during the treatment without manipulating the needles.
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Elden et al., 2005
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Standard treatment plus acupuncture.
Standard treatment consisted of general information about the condition and anatomy of the back and pelvis. Adequate advice was given about activities of daily living. The physiotherapist made sure that the patient understood and respected the relation between impairment, load demand, and actual loading capacity as well as the importance of necessary rest. The purpose of this information was to reduce fear and to enable patients to become active in their own treatment. The patients were given a pelvic belt and a home exercise programme designed to increase strength in the abdominal and gluteal muscles.
Acupuncture – the Patients received the same treatment as in the standard group but in addition had acupuncture. Local acupuncture points were selected individually after diagnostic palpation to identify sensitive spots. A total of 10 segmental points and seven extrasegmental points were used. The needles were made of stainless steel and inserted intramuscularly to a depth of 15-70 mm to evoke needle sensation, described as tension, numbness, and often a radiating sensation from the point of insertion, reflecting activation of muscle-nerve afferents. The needles were left in situ for 30 minutes and manually stimulated
every 10 minutes. Treatment was given twice a week over six weeks. Fetal heart rate and maternal heart rate and blood pressure were monitored before and after all treatments.
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Standard treatment plus stabilizing exercises
Stabilising exercises – patients received the same treatment as in the standard group but in addition did stabilising exercises modified because of the pregnancy (box). The training programme started by emphasising activation and control of local deep lumbopelvic muscles. Training of more superficial muscles in dynamic exercises to improve mobility, strength, and endurance capacity was gradually included. Patients received treatments individually for a total of six hours during six weeks. They were told to integrate the exercises in daily activities and to exercise in short sessions on several occasions during the day.
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Kvorning et al., 2004
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Acupuncture. In the acupuncture group, acupuncture was given
according to written instructions and periostal stimulation was used when possible. Initially the acupuncture points LR3 and GV20 (if the patient was nervous) were stimulated together with local tender points (TP). If the response was insufficient, stimulation at some of these points was combined with stimulation at the points BL60, SI3 or (using 2.5-inch needles) at one of the following locations: the lumbar and sacral bladder points BL22–26 (tangentially), the minimal gluteal muscle tendon 3–4 cm distal to the anterior superior iliac spine (tangentially), the sacroiliac tendons (obliquely towards the distal part of the ligament) or (using 1.0-inch needles) at the symphysis (perpendicularly). On the first visit, Dechi (a Chinese word meaning ‘‘arrival of energy’’ and reported by patients as a characteristic feeling of local pain, heat, numbness or soreness) was achieved once at up to eight different acupuncture or trigger points. On later visits, manipulation of the needle was stopped as soon as Dechi was obvious but repeated after 30–60 s with the needle left in place between the two stimulations. After this, the needles were removed and the patient allowed to rest for at least 10 min. In the first 2 week period patients were given acupuncture twice a week and later on no more
than once a week.
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Control patients were given no sham stimulation.
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Ekdahl and Petersson, 2010
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Acupuncture treatment from gestational week 20 (group 1) for a period of 6 weeks divided into eight sessions of 30 minutes each. The first session lasted 20 minutes and the number of needles was limited to five. Subsequent sessions were of 30 minutes duration and the number of needles limited to 10. All women received the same treatment. Foetal sound was measured before and after each treatment occasion. Using known anatomical sites as reference points the acupuncture sites are defined, more easily if they are tender. Needle
sensitivity is called ‘deqi’ in Chinese and means ‘arrival of energy’ and according to western research deqi-sensitivity is due to stimulation of deep muscle afferent’s. Once the needle has been placed and the specific needle sensitivity (deqi) has developed the needle is left in place 20–30 minutes.
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Acupuncture treatment from gestational week 26 (group 2) for a period of 6 weeks divided into eight sessions of 30 minutes each. The same procedure as in group 1.
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Vas et al., 2019
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i. Standard obstetric care plus 2 sessions (over 2 weeks) of verum ear acupuncture. Auricular pressure needles, 1.5 mm long and 0.20 mm in diameter were applied at two standardized points (Shenmen and Kidney), and at a reflex point in the region of the ear that classically represents the lumbar or sacral regions. This point was detected by means of a probe calibrated at 250 grams of pressure.
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i. Standard obstetric care plus nonspecific ear acupuncture.
The same type of needle was used as in the verum ear acupuncture group, but the needles were applied at ear points that are not specific for lower back and/or posterior pelvic girdle pain, and that instead correspond to anatomical locations in the ankle, wrist and shoulder.
ii. Standard obstetric care plus placebo ear acupuncture. The placebo devices were identical to those used in the verum ear acupuncture group, but were devoid of a needle, and were applied at the same nonspecific points as for the nonspecific ear acupuncture group.
iii.Standard obstetric care alone included an explanation of the cause of lumbar or pelvic pain and recommended self‐care procedures, both to prevent pain and reduce its intensity, together with training in specific stretching exercises for the back and hamstring muscles. Women were recommended to use acetaminophen (paracetamol) and/or visit their GP if the intensity of the pain increased.
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Elden et al., 2013
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Standard treatment plus craniosacral therapy.
Women in the intervention group received the same treatment as the control group but received craniosacral therapy as well. They were treated with a manual release technique of the pelvis while supine. The therapist attempted release of tension in the fascia, ligaments and muscles using L5–S1 release, sacroiliac release, superior and inferior pubis symphysis release (14), i.e. a standardized functional therapy postulated as effective for PGP during pregnancy. The hands-on treatment took 45 minutes once weekly for 2 weeks, and every second week for 6 weeks. Two qualified, experienced (range 14–16 years of experience) craniosacral therapists provided the treatment.
They met frequently throughout the trial to ensure that treatment and consultation types were as comparable and equivalent as possible.
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Standard treatment.
Standard treatment consisted of general information about the condition and anatomy of the back and pelvis. The physiotherapist informed the woman of the relation between impairment, load demand, actual loading capacity and importance of necessary rest. Advice was given with respect to activities of daily living. The women received
an elastic pelvic belt (Puff Ig ang AB, Gothenburg, Sweden) and a home training program including exercises to strengthen and stretch the trunk, hip and shoulder muscles. If exercises aggravated the pain, the women were advised to contact the physiotherapist for further instructions. In addition, they could always call the physiotherapist if they had questions or needed additional advice or crutches. Information was supplemented by a leaflet. All women met the physiotherapist twice, first at inclusion and then at the follow up. Women needing treatment at the follow-up visit were referred to a physiotherapist with special knowledge of pelvic girdle pain.
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Peterson et al., 2012
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Exercise participants were given a booklet and enthusiastically instructed on pelvic tilts, pelvic floor, gluteus maximus, latissimus dorsi, and hip adductor strengthening exercises to promote low back stability and flexibility. The specific exercises in the booklet have been shown to decrease pregnancy related low back pain. The booklet also instructed exercise participants on recommendations for postural and movement patterns that help alleviate low back pain. Finally, warnings in the booklet about when to stop exercising were reviewed with the participant. At each study visit exercises and lifestyle suggestions were reviewed and practiced with participants. Additional
individualized stretching or strengthening exercises were prescribed, demonstrated, and practiced at each study visit based on muscle strength and flexibility assessment. Exercises took about 15 min to perform at home and
participants were requested to exercise five times weekly.
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Participants in the Spinal Manipulative Therapy group were palpated to determine if each had intersegmental dysfunction prior to manipulating. Hypomobile joints were isolated through positioning, then a slow force was applied to preload the joint at the physiological end range. After loading the joint, a high velocity, low amplitude thrust was applied to the isolated joint to move it just past the physiological end range in the side posture position for lumbar and sacroiliac lesions. The thrust was applied in
the direction, velocity, and amplitude as determined by the clinician from the palpation exam findings. A hypermobile joint or region was stabilized by creating a fulcrum at a specific joint by the participant lying on padded blocks. The blocks were always used to adjust a Sacro Occipital Technique Category II pelvis, and the Activator was always used to adjust the pubic symphysis. Neuro Emotional Technique (NET) is a chiropractic mind-body technique that combines desensitization procedures (such as relaxed breathing and visualization) with elements of Five Element Chinese medicine (such as the association of emotions with certain organs or meridians) and chiropractic medicine (the adjustment of the spinal levels that innervate the organ in question) in an attempt to address cognitive distortions through the use of a semantic algorithm. The reliability and validity of the manual muscle testing used to guide
the technique are unknown, but muscle testing is considered to be part of the treatment package of NET. The NET standard protocol was followed.
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Lisi, 2006
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Chiropractic treatment including spinal manipulation. Active care consisted of reassurance and education, advice on body mechanics, and exercise instruction. Passive treatments were manual myofascial release, manual joint mobilization, and manual spinal manipulation. The most commonly used spinal manipulation manoeuvres were procedures aimed at the lumbar facet joints and/or the sacroiliac joints. This involves the subject lying in the lateral decubitus position with the hip and knee flexed, upper extremities folded, and forearms resting on the chest. The chiropractor stands facing the subject at approximately a 45° angle to the table. The chiropractor contacts the given region of the subject’s spine with the hypothenar region of one hand; the other hand contacts the subject’s crossed forearms. At first, relatively low offsetting forces are applied to bring the spinal region to the end range of passive motion. Next, the high-velocity, low-amplitude thrust is delivered. For the women in this study, modifications in technique delivery were made to ensure comfort
and avoid abdominal compression; and the clinician attempted to use the lowest amount of force necessary. However, the goal of each spinal manipulation procedure was grade V joint motion and articular cavitation or “popping,” and this occurred in most instances.
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No control group
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Licciardone et al., 2010
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Usual obstetric care and osteopathic manipulative treatment.
The osteopathic manipulative treatment protocol consisted of a standardized approach whereby each assigned subject received treatment provided by licensed physician faculty within the Department of Osteopathic Manipulative Medicine at the University of North Texas Health Science Center. The study protocol included any of the following treatment modalities: soft tissue,
myofascial release, muscle energy, and range-of-motion mobilization. These modalities were used in a systematic manner within a protocol that enabled the physician to identify and treat specific somatic dysfunctions in the following anatomic regions: cervical, thoracic, and lumbar spine; thoracic outlet and clavicles; ribcage and diaphragm; and pelvis and sacrum. Treatment providers met regularly to ensure consistency in the duration, type, anatomic location, and manner of manipulation provided throughout the trial. The study protocol prohibited use of high-velocity, low-amplitude techniques because the increasing ligamentous laxity that occurs in late pregnancy may pose a theoretical risk in performing such maneuvers. A cranial technique known as compression of the fourth ventricle (CV-4) was also prohibited on theoretical grounds that it may potentially induce premature labor, although the small uncontrolled study suggesting that CV-4 may initiate uterine contractions involved only postdate women.
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Usual obstetric care and sham ultrasound treatment
Or
Usual obstetric care
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Licciardone & Aryal, 2013
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Usual obstetric care and osteopathic manual treatment (OMT). The OMT protocol included the following techniques: soft tissue, myofascial release, range-of-motion, and muscle energy. These techniques were aimed at somatic dysfunction involving the cervical, thoracic, and lumbar spine; sacrum and pelvis; thoracic outlet and clavicles; and ribcage and diaphragm. The OMT protocol precluded use of high-velocity, low amplitude thrusts and compression of the fourth ventricle on the theoretical grounds that these techniques may pose risks to the patient or fetus or may induce premature labor, respectively.
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Usual obstetric care and sham ultrasound treatment
Or
Usual obstetric care only
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Hensel et al., 2015
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Usual care plus osteopathic manipulative treatment.
Techniques applied included: seated thoracic articulation, cervical soft tissue, occipito-atlantal decompression, thoracic inlet myofascial release, lateral recumbent scapulothoracic soft tissue, lateral recumbent lumbar soft tissue, abdominal diaphragm myofascial release, pelvic diaphragm myofascial release, sacroiliac articulation, pubic symphysis decompression, frog-leg sacral release, compression of the fourth ventricle (CV4).
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Usual care plus
placebo ultrasound treatment
or
usual care only
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Nilsson Wikmar et al., 2005
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Home Exercise Group received information and a sacroiliac belt as the Information Group, but in addition, they were given a home exercise program consisting of 3 exercises aiming to stabilize the muscles around the pelvic girdle. The exercises were performed with a ball between the knees in sitting, in standing, and in 4-point kneeling position with movements of the arms or the legs. The program was ended with stretching of the hamstrings, hip flexors, and calf muscles. The instructions about the program were given within 1 week after inclusion, and the women were followed up once shortly after receiving the program. As in the Information Group, they were free to call the physical therapist at any time during pregnancy. The number of exercise occasions in the home exercise group was not recorded.
The In Clinic (outpatient treatment) Exercise Group received information and a sacroiliac belt in the same way as the Information Group, but in addition participated in a training program comprised of 4 different strengthening and stabilization exercises with different pieces of equipment; the lateral pulls, standing leg-press, sit-down rowing, and curl-ups. The adjustment of the load, number of sets, and repetitions was calculated based on 20 maximal repetitions, and the exercises were carried out with the adjusted load for 3 series of 15 repetitions. For warm-up, biking on a stationary bike was used. The program was ended with stretching. The exercises were performed twice a week until gestation week. A physical therapist gave the instructions twice, and thereafter the patient exercised alone, but with the ability to ask a physical therapist for further instructions or adjustments of the load. All treatments were given individually during pregnancy. The In Clinic Exercise Group exercised on average 16 times (range 4–51).
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Information group – received information about the condition including anatomy, body posture, and ergonomic advice and were provided with a nonelastic sacroiliac belt. They were able to call the physical therapist at any time during pregnancy should more questions arise about the condition.
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Smith and Michel, 2006
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Exercise group. The aquatic exercise program was a 6-week program, with three sessions (each lasting 60 minutes) per week. The first 10 minutes of the class involved warm-up exercises and stretches. Next, the continual movement phase lasted 25 to 30 minutes. During this portion of the class, exercises targeted large muscles of the body, such as the legs and buttocks. Participants were instructed to self-monitor their level of exercise intensity using the Perceived Level of Exertion Scale (PLES). The PLES is a visual analogue scale ranging from 6 to 20, with the safe intensity range for pregnant women between 12 and 16. The last phase of class (10-15 minutes) was designed to strengthen the abdominal muscles, stretch the muscles of the lower portion of the back, and promote flexibility. After this, a warm-down, stretch-out, and relaxation session concluded the class. The aquatic exercise program was a 6-week program, with three sessions per week.
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Non-exercise group.
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Backhausen et al., 2017
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Unsupervised water exercise twice a week for a period of 12 weeks. The water exercise intervention was performed between 20 and 32 gestational weeks and
initiated by an introductory session at a public indoor swimming pool, followed by 12 weeks of unsupervised exercises twice a week. The introductory session consisted of a theoretical part led by two of the authors where the participants were given theoretical counselling about general exercise recommendations during pregnancy and shown short movie clips
of the six Aqua Mama water exercises. Subsequently, the women were given practical instructions by specially trained coaches while performing the exercises in water. The participants were encouraged to keep a training logbook that was handed out during the introductory session. A brush-up session was offered twice during the water exercise period to give an opportunity to ask questions regarding the exercises. Engagement in other physical activities were encouraged and allowed, due to national recommendations of 3.5 hours of weekly exercise. Free access was given to seven public swimming pools in Copenhagen city. Short weekly motivating
emails were sent to remind the participants to follow the water exercise program. An exercise session consisted of: four swimming laps (100 m in total) as a warm up, followed by the six AquaMama exercises MamaSurf; MamaPendul; MamaJogging; MamaLift; MamaBoxing; MamaBiceps) and finished with another four laps. The six exercises (were performed in two series and required two foam dumbbells, a swim belt and a kickboard. Short movie clips of each exercise were shown.
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Standard prenatal care.
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Granath et al. 2006
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A land-based physical exercise program once a week during pregnancy.
The main difference between interventions was the aquatic environments elimination of gravity and dampening resistance to movement. The movements in both interventions targeted similar muscle groups.
45 minutes of activity followed by 15 minutes of relaxation. Weekly
group interventions. Interventions were focused on strength, flexibility, and
fitness, and included warming up, stretching, and relaxation at the end of each session. Land-based physical exercise was a set of exercises developed by physiotherapists for fitness during pregnancy. They consisted of movements
accompanied by music of varying tempos. Focus was on improving aerobic and movement capacity including light jogging, sit-ups, and pelvic mobility exercises.
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Water aerobics once a week during pregnancy. 45 minutes of activity followed by 15 minutes of relaxation. Weekly
group interventions. Interventions were focused on strength, flexibility, and fitness, and included warming up, stretching, and relaxation at the end of each session. Water aerobics consisted of exercises developed by midwives and physiotherapists for pregnant women. Water aerobics had the same focus on aerobic and movement capacity as LBPE but with considerably less risk for unwanted weight-bearing loading of anatomic structures.
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Kihlstrand et al., 1999
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People in this group were offered water-gymnastics once a week during the second half of pregnancy. The water-gymnastics group included ten classes of 12–15 women and took place in a swimming pool with a water temperature of 32–34 degrees Celsius. The exercises were recommended by the Swedish Swimming Society and tested for pregnant women by physiotherapists. The women were offered water-gymnastics 17–20 times (once a week during the second half of pregnancy). Each training session lasted one hour and included relaxing exercises. Two different exercise programs were used for all women; one with exercises suitable for earlier pregnancy to be used for the first ten training sessions, and one with exercises suitable for later pregnancy for the last ten sessions. The physical training lasted for 30 minutes followed by 30 minutes of relaxation, all in water and to music adjusted to the different exercises and to relaxation.
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This group was not offered water gymnastics.
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Chandrasekharan et al., 2020
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Back-stretch exercise. the women of the study group were asked to stretch the back for 3-4 seconds then to relax and then to lay on the floor with knees up and feet flat with soles of feet. The backside, mid/ upper back, shoulders, and head were touching the floor, and the women were asked to maintain a space between the floor and low back as well as neck. Slow inhalation was encouraged to bring it to the abdomen, then towards the back and then were asked to exhale out slowly. The women were asked to continue the pulling and allowed the spine and pelvis to return to their original position. The women were advised to do the same at least 4 times a day for 5-10 minutes and to stop the exercise in case of excessive fatigue, shortness of breath, feeling faint, difficulty in walking, marked decrease in movement of the baby, and dizziness. Participants were motivated to perform the exercise in the morning and mid-afternoon under the supervision of the researcher as the researcher visited the pregnant women in their home every day. However, the pregnant women were reminded through a telephonic call to perform the exercise for the remaining two times a day. Further reinforcement was done by the researchers when the women visited the antenatal outpatient department during their subsequent visits. The control group continued the routine care. The women of the study group were advised not to use any other strategies to relieve back pain to prevent the influence of extraneous variables on the outcome of the study. A stretching exercise practice checklist was asked to be maintained by pregnant women. It was counter checked by the investigators of the study.
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No treatment control group.
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Yousefabadi et al., 2019
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Stretching and strengthening exercises. Exercise was as follows:
1. Posterior pelvic tilt (located in the fours, hands across shoulders, and knees are shoulder-width apart, body weight given to the hips. abdominal muscles contract slightly)
2. Practice in the supine position (lying on the back, legs apart and feet on the floor, inhale, and then lift up with expiratory muscles of the buttocks. With the support of hand below the hips, loose the hips and back softly to the ground)
3. Stretch the upper back (squeezing the buttocks and the soles of the prostrate with outstretched hands forward along with normal breathing)
4. Stretch the hamstring muscles (legs stretched out and the body to the foot pull a few seconds in the hold mode. Bend body from the hips and try to drag chest to foot. The body in hold mode and feel the tension in the back of the thighs).
These exercises were performed at home for 3 days a week, twice a day (morning and evening) each time for 15 min, for 6 weeks.
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The control group received routine prenatal education.
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Pont et al., 2019
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Yoga
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No control group
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Eggen et al., 2012
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Group-based exercises, information, and home exercises. Supervised exercises, including ergonomic advice, in groups and were advised to do home exercises. Each weekly group exercise session lasted 60 minutes, and the groups trained for 16 to 20 weeks (between gestation weeks 16 and 36). The goal of the exercises was to achieve efficient motor control and the ability to dynamically control and stabilize the lumbopelvic region during daily activities. Attention was paid to body awareness, posture, and ergonomic advice in real-life situations (eg, maintaining neutral position of the lumbosacral region while standing, walking, lifting, and bending). The exercises focused on activity of local muscles (eg, pelvic-floor muscles, transversely oriented abdominal muscles), with coordinated activity of global muscles such as the gluteus maximus, oblique abdominal, and hip and thigh muscles. The exercises were intended to avoid inducing pain. Individual guidance was given, and exercises were adjusted by the physical therapist. To ensure that the observer had personal contact and was able to observe each individual’s performance of the exercises, a maximum of 8 women participated in each group. Each group training session started with 20 to 30 minutes of aerobic activity, including stepping, walking, or light jogging on a BOSU* balance ball (Team BOSU, Canton, Ohio), accompanied by varied arm movements. Following the aerobic
activity, the women performed knee bends, toe raises, and pelvic floor muscle contractions in couples. Furthermore, the women performed 4 standardized exercises such as the “birddog,” the “buttock lift,” leaning forward with the arms against a wall or in ropes, and sitting on a Swiss ball with or without the feet on the floor. For all of the exercises, we emphasized maintaining the neutral position of the lumbosacral region. If one exercise provoked pain, an alternative exercise was sought, and attention was paid to relaxed breathing during exercising. Mobilizing and rotational exercises for the lumbar and
thoracic lumbar regions also were a part of the exercise session. The training session ended with relaxation and stretching of hip and thigh muscles. The women received information about normal changes in pregnancy, ergonomic advice, and reminders about the importance of combining physical activity with short breaks and optimal rest. They were further encouraged to perform 3 home exercises daily. The first exercise was similar to one of the group exercises. While leaning forward with the arms against a wall, the women were supposed to maintain control of the lumbopelvic region with activation of the pelvic floor muscles and the transversely oriented abdominal muscles. The
second exercise consisted of knee bends to strengthen the thighs while maintaining the lumbosacral region in neutral. The last exercise was a stretching exercise for sustaining muscle length of the external rotators of the hip. Performing the home exercises took approximately 4 minutes to complete, and the women were encouraged to register adherence with the aid of a training diary; however, no data were collected. No charge was incurred for the treatment. They were allowed to exercise on their own if they wanted to do so, and treatment was not discontinued during pregnancy.
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The women in the control group received standard care (regular visits every fourth week at the maternity primary care centers, including information and advice for health complaints provided by the midwife). They were allowed to exercise on their own if they wanted to do so, and treatment was not discontinued during pregnancy.
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Haakstad & Bø, 2015
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Prescribed to participate in at least 2 out of 3 possible 1-hour aerobic dance classes per week, for a minimum of 12 weeks. Each session started with 5 min warm up, followed by 35 min endurance training and aerobic dance, including
cool down. This was followed by 15 min strength training with a special focus on the deep abdominal stabilization muscles (internal oblique and the transverse abdominal muscle), pelvic floor and back muscles. The last 5 min included stretching, relaxation and body awareness exercises. The aerobic dance routine included low impact exercises (no jumping or running) and step training. Step length and body rotations were reduced to a minimum, and crossings of legs and sharp and abrupt changes of position were avoided. The exercise programme followed the current American Congress of Obstetricians and Gynecologists (ACOG) exercise prescription (10, 16), and all aerobic activities were performed at moderate intensity measured by ratings of perceived exertion at 12–14 (somewhat hard) on the 6–20 Borg rating scale. The exercise programme was choreographed and led by certified aerobic instructors. In addition to joining the scheduled aerobic classes, all women in the exercise group were asked to include 30 min of moderate self-imposed
physical activity on the remaining week days. They were also advised to incorporate short bouts of activity into their daily schedules (e.g. to walk instead of drive short distances and to use stairs instead of lifts). Adherence to the exercise classes was reported by the aerobic instructors, and the self-imposed daily activity was registered in a personal training diary.
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Usual prenatal care. Control participants were neither encouraged to, nor discouraged from, exercising, as we considered asking the controls not to exercise to be against current guidelines. In order to treat the 2 groups identically
apart from for the intervention, the control group underwent all tests and completed the same interview as the exercise group. Otherwise, the control group received usual prenatal care.
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Martins & Pinto e Silva, 2014
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Pregnant women from the yoga group (a maximum of 10 per group) participated in 10 Yoga sessions once a week for 1 hour each. Sessions were administered by one researcher, who is a physical therapist and licensed Hatha yoga instructor. For treatment, 34 poses (asanas) were chosen to stimulate the
psychophysical effects, such as joint range of motion, flexibility, strengthening, muscular resistance, balance, stimulation of introspection, self-confidence, self-control, concentration, and mental relaxation. The breathing exercises performed were complete breathing, square breathing, and polarized breathing.
Sessions were divided into three time points: Initially, attention was focused on the breathing rhythm and warm-up of the major joints (10 minutes) in a moment of introspection, followed by poses and breathing exercises (40 minutes). In the end, women listened to messages of meditation and relaxation (10 minutes). At the beginning and end of each session, pain intensity was assessed. Treatment in each group lasted 10 weeks.
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Pregnant women in the control postural orientation group
received a pamphlet on postural orientation that contained figures and text explaining some possible changes in the curvature of the vertebral spine during pregnancy (hyperlordosis and hyperkyphosis). Suggestions concerning spinal positioning were made for daily activities, while lying down (to lie on one’s side with a proper support for the head and abdomen and between the knees), while sitting (to have adequate lumbar and foot support), and while standing (to have feet supported and to lengthen the handle of the broomstick). Treatment in each group lasted 10 weeks.
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Flack et al., 2015
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A wide, flexible neoprene support belt (Smiley Belt, www.smileybelt.co.nz, Havelock North, New Zealand)
Participants were shown by a physiotherapist how to wear the belt, aligned over the pubic symphysis (the so called ‘low position’) and were advised to wear it whenever possible during waking hours.
Women were sent automated standardized daily text messages and asked to respond on the number of hours the belt had been worn, whether pain had decreased (yes/no/sometimes) and if functional activities were easier to perform (yes/no/sometimes). Responses to daily text messages were recorded.
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Thinner, more rigid belt made of nylon webbing with foam lining (LC symphysis pubis belt, The Orthotic Center New Zealand Limited, Greenlane, Auckland, New Zealand; NZD).
Participants were shown by a physiotherapist (SW) how to wear the belt, aligned over the pubic symphysis (the so called ‘low position’ and were advised to wear it whenever possible during waking hours. Women were sent automated standardized daily text messages and asked to respond on the number of hours the belt had been worn, whether pain had decreased (yes/no/sometimes) and if functional activities were easier to perform (yes/no/sometimes). Responses to daily text messages were recorded.
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Delshad et al., 2020
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Three randomized conditions including no pelvic belt (control), with a pelvic belt, and while a sacral pad was used with the pelvic belt.
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Three randomized conditions including no pelvic belt (control), with a pelvic belt, and while a sacral pad was used with the pelvic belt.
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Shim et al., 2007
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The programme consists of a standardized education protocol: pamphlet,
lecture, audiovisual tape to demonstrate the exercise, daily exercise record, and telephone calls. The program was provided only to the intervention group, and was supervised by the first author. A 45-min programme regarding simple anatomy and function of the vertebrae, normal pelvic changes that occur during pregnancy, factors related to lumbar and pelvic pain during pregnancy, and the appropriate body posture to prevent back pain, was given during an antenatal class. All participants in the intervention group were taught to perform the back-pain-reducing exercise and then asked to do them at home. Two to seven subjects participated in each educational lecture and a total of nine lectures
were held by the first author. The pamphlet was given to all participants in the intervention group. An audio-visual tape was distributed to all of the women in the intervention group. This 12-min-long tape demonstrated an exercise program that was specially designed for this study based on William’s
flexion exercise program to reduce back pain during pregnancy. The six sets of exercise demonstrated were designed to relieve back pain in pregnant women, and included pelvic tilting, knee pull, straight leg raising, curl up, lateral straight leg raising, and the Kegel exercise. The women were encouraged do this exercise at home 5–7 times a week and record their daily exercise on a daily exercise record. The women in the intervention group received one or two telephone calls per week from the first author to encourage them, reinforce the concept of performing regular exercise, and to assess the intensity of their back pain.
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Usual care (another antenatal clinic).
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Khalednezhad et al., 2017
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Backache preventive behavioural programme. Theoretical materials were taught by a health educator (researcher), and training exercises practically were taught simply and smoothly in 8 sessions. The sessions from first to eighth were held in the pregnancy weeks of 20 -23th, 24-27th, 28-29th, 30-31st, 32-33rd, 34-35th, 36th, and 37th week of the pregnancy. Each session lasted for 90 minutes consisting of 15 minutes for each other familiarity, 30 minutes for theoretical training about the importance of the exercise and preparation for a healthy pregnancy and childbirth, 45 minutes for training in breathing techniques and practical training in body posture reform, relaxation, and massage along with watching educational films about the sports and
relaxation during pregnancy. It was also reminded that these exercises be repeated at least 2 times per week by the pregnant women at home. Training sessions were consisted of educational materials suitable for pregnancy age, which were focused on the cause of back pain in pregnancy and preventive behaviors, including how to sleep, sit, and walk properly in pregnancy, as well as how to lift objects correctly. In these sessions the questions were answered. Then practical movements including several sections of stretch-resistance movements, breathing exercises, relaxation, and massage were taught in training sessions. The materials were selected from the book “antenatal
education and preparation for childbirth” of the ministry of health, according to the American College of Obstetricians and Gynaecology (ACOG). Also, the materials were included in a brochure available for the intervention group. Personal abilities were taken into account in repetition and intensity of each exercise. Educational films were shown in training classes in order to better understand how to correctly perform exercise movements, sleeping, siting, standing, and relaxing.
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Control group received no documented intervention.
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Ōstgaard et al., 1994
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Group B: back school education and training programme. Two 45-minute classes, with five to eight participants, were given before the 20th week of pregnancy and included simple anatomy, posture physiology, lifting and working technique, muscle training, and relaxation training. A written summary of the content of the lessons was given to each woman.
Group C: all women were offered a back school education and training programme with the same content as in group B, but the education was given individually and for a longer period – five 30-minute lessons during pregnancy weeks 18 to 32. The first two lessons included body posture and individually designed ergonomic advice and were given before the 20th week. The remaining three lessons were given at 4- to 6-week intervals. The training programme was recorded on a music cassette and was given together with written instructions to each woman in group C with a recommendation to perform the programme at home three times a week. The programme was individualised according to the woman’s specific type of problem; back, pelvic, or a combination of the two. Also, the woman’s working conditions were considered. Women without any back or posterior pelvic problems were given the back school education as a prophylaxis.
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Group A: Usual care.
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Norén et al., 1997
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Individual information including ergonomic advice and differentiated physiotherapy.
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Usual care at another antenatal clinic.
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Bastiaenen et al., 2006
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Women, allocated to the intervention group, were referred to a participating physiotherapist in their own neighbourhood. These physiotherapists received an educational programme about the treatment protocol prior and during the
study. All physiotherapists were already experienced and specialized in treating women with pregnancy-related pelvic girdle pain prior to the study. The content of the experimental intervention was based on the latest literature findings. It focused particularly on patient-therapist relationship, education and the promotion of an active life style rather than avoiding activities. Results of interviews with women from the cohort and group discussions with
experienced physiotherapists prior to the trial further defined the programme. Theoretical concepts of self-management and fear-avoidance were integrated in the intervention protocol. We provided an individualized self-management approach of 7–9 sessions for 30 minutes once a week. Standardized information was presented by means of an intervention protocol for the therapists and by booklets for the patients. Topics included back and pelvis anatomy, "red flags" indicating a serious medical condition, factors contributing to fluctuations in pain, appropriate pacing of exercise and activity, handling pain flare-ups, cognitive restructuring, some graded exposure techniques, communication and social persuasion. Therapists had to employ simple problem-solving techniques that engaged women in identifying day-to-day problems or limitations related to pelvic girdle an/or low back pain, setting personal goals, brainstorming options for achieving these goals and developing personal action plans. In subsequent sessions, women reviewed their action plans and their progress towards goals and engaged in problem-solving skills concerning difficulties that arose in trying to implement their plans. Information about two opposing behavioural responses of pain-related fear (avoidance and confrontation) was given and a hierarchy of individual fear-eliciting movements and activities was made. Therapists encouraged women in
making action plans with respect to graded exposure techniques in specific activities that were avoided. They were explicitly asked not to "label" the complaints in terms of medical diagnostics. Generally, a time contingent policy was followed in which women set the pace by means of action plans. The expertise of the physiotherapists of the condition in general and of the women about their own specific condition and lives were equally important.
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Usual Care. Women, allocated to the usual care group, were free to
choose usual care treatment by an experienced physiotherapist who did not follow the educational programme
about the treatment protocol, guidance by a general practitioner,
or do nothing.
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Kaplan et al., 2016
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Paracetamol plus kinesiotaping therapy. All participants in the
Kinesiotaping group were taped by the same physician. Kinesiotaping was applied when the lumbar flexion reached its maximum point. Four I-shaped Kinesio bands (Kinesio tape., Libor, Turkey) with a width of 5 cm and thickness of 0.5 mm were used. Two bands, 1 on each side of the lumbar spine, were applied vertically from the lower posterior iliac crest region to the upper twelfth rib region, with inhibition technique. The remaining 2 bands were attached horizontally, with space correction technique. All 4 bands were placed to allow for 50% longitudinal stretching. The stretching directions for the vertical and horizontal applications were bottom-up and sideways, respectively. The aim of these applications was to relieve both lumbar and pelvic girdle pain.
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Paracetamol only
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Aalishahi et al., 2022
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Kinesiotape. Firstly, the implant area was shaved, and the patient was asked to bend forward. Next, a Kinesiotape with an approximate length of 20 cm and a width of 5 cm with 50% tension was placed on the skin cleaned without grease and lotion. from the bottom of the pain area to the top in the vertical position with a distance of 2 cm from the spine. Another strip was placed in the same way on the other side of the spine at a distance of 4 cm from the previous strip. Next, another strip with the same dimensions, but with 70% tension was transversely attached to the sacroiliac joint. To reduce the pressure of the lumbar vertebrae and support abdominal muscles, a tape was placed without stretching under the abdomen.
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Placebo tape. In the control group, the placebo tape, i.e. the Leukoplast adhesive tape with the width of 5 cm was placed in the same way in the intervention group.
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George et al., 2013
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Standard obstetric Care plus multimodal approach of musculoskeletal and obstetric management. Like the standard obstetric care group, the frequency of obstetrics visits for patients in the multimodal approach of musculoskeletal and obstetric management group was also dictated by their self-chosen obstetrics providers. The multimodal approach of musculoskeletal and obstetric management group additionally had weekly visits with a chiropractic specialist who provided education, manual therapy, and stabilization exercises, based on the biopsychosocial model. The biopsychosocial model explains that a patient’s pain syndrome is not comprised solely of the injured body structure but also includes psychologic and social components, such as fear of movement and high pain expectancy. Patients were reassured the pain experienced was unlikely pathologic and that reactivation of joint and muscle mobility by exercise would likely improve symptoms and signs without posing risk to the patient or her fetus. The goal of manual therapy was to restore
joint motion and reduce muscletension. Hypomobile joints were assessed with the long dorsal ligament test, posterior PP provocation test, and clinical palpation and were treated with routine joint mobilization. Joint mobilization
techniques were performed by gently moving hypomobile joints in their restricted directions to help restore proper range of motion. Muscle tension was evaluated by clinical palpation and was treated with post isometric relaxation and myofascial release. The stabilization exercises were targeted to strengthen the muscles that supported the low back and pelvis, because these muscles maintain the spine and hip stability that are important for the increased load that is created by pregnancy. The gluteus maximus, gluteus medius, quadratus lumborum, abdominal wall, and intrinsic spine muscles were targeted in the quadruped, supine, or side-lying positions. Patients were instructed to perform their home exercise program twice daily. Patient compliance with their home exercise program was not tracked but was encouraged with each follow-up visit. Self-administered exercises initially were selected from a standardized protocol that is used for low back and pelvic stabilization. Sacroiliac belts were reserved for cases with significant hypermobility or when a patient’s pain restricted exercise performance. Patients who were assigned to the multimodal approach of musculoskeletal and obstetric management group had weekly appointments with the chiropractic specialist until 33 weeks’ gestation.
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Standard obstetric Care group received total care from a self-chosen obstetric provider who had the discretion to recommend 1 of the following remedies: rest, aerobic exercise, heating pad application for a maximum length of 10 minutes, use of acetaminophen for mild pain, or narcotics for discomfort unrelieved by other measures. Referral to orthopedic or neurologic services was used for cases in which pain was debilitating or unresponsive to standard modalities.
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