Prevalence, Perception and Risk Factors for Musculoskeletal Discomfort among Pregnant Women in Southeast Nigeria

Background: Hormonal and physical adaptations to pregnancy may result in musculoskeletal discomforts. The pattern and perception of these disturbances may form the basis for the health-seeking behaviours adopted by the pregnant women. Objective: To determine the pattern of, perception on, and biosocial risk factors to musculoskeletal discomfort among pregnant women in South Eastern Nigeria. Subjects and method: This is a cross-sectional, interviewer-administered questionnaire-based study of 115 pregnant women attending antenatal-care outreaches in South Eastern Nigeria. Results: One hundred and fifteen antenatal volunteers were interviewed, majority were traders (50.4%) and within the age bracket of 26-30 years (45.2%). Most were of parity 1-4 (68.7%) and predominantly of social class 3 (60.0%). Up to 85 (73.9%) of the respondent had heard of musculoskeletal discomfort (MSD) during pregnancy while 55.7% had experienced it in the index pregnancy, and 32% in the last pregnancy. The types of MSD experienced in the index pregnancy includes pelvic pain 45 (70.3%), leg pain 16 (25%), low back pain 15 (23.4%), and coccydynia 1 (1.6%). The major causes of discomfort were attributed to malnutrition (55.6%), strenuous activity (54.7%), big baby (35.7%), pregnancy hormones (21.8%), and too many pregnancies (18.2%). Thirty-three (28.7%) respondents attributed MSD complications to miscarriage and premature deliveries. Experience of MSD, measured as discomfort respondent ratio (DRR) was high at extremes of maternal age, and increased with increasing gestational age, parity and social class. A significantly large number 30 (46.9%) had no form of treatment for their discomfort, while a few others applied a wrong treatment like antibiotics 1 (1.6%) and herbal concoctions 1 (1.6%). Conclusion: This study showed a higher level of awareness and experience of musculoskeletal discomfort amongst the respondents. There was however insufficient knowledge as to the causes, risk factors, treatment and possible complications among them. Pelvic pain, leg pain and low back pain were the most commonly observed musculoskeletal discomfort amongst the respondents. Recommendation: Health workers and pregnant women should have adequate knowledge, information and education on the various types of musculoskeletal discomforts as well as their causes, management and treatment as part of a comprehensive pregnancy health education package. ISSN: 2572-3243 DOI: 10.23937/2572-3243.1510063 Adinma et al. J Musculoskelet Disord Treat 2018, 4:063 • Page 2 of 9 • caesarean delivery [1]. Hip pain in pregnancy can result from osteonecrosis of the femoral head and transient osteoporosis of the hip. The former is rare with unclear aetiology, but may be secondary to weight gain, endogenous production of glucocorticoids by the adrenal gland [11], or a hypercoagulable state. It manifests as hip pain radiating to the groin or lateral thigh, particularly with weightbearing. Transient osteoporosis of the hip also presents with pain on activity and limitation of motion of the hip. In contrast to osteonecrosis which may be progressive, transient idiopathic osteoporosis resolves by six to eight months postpartum with conservative therapy [12]. Knee pain including patellofemoral disorder are not uncommon in pregnancy. Postural changes, increase in weight, and increased laxity of ligaments can all contribute to pain in the knee. There is marked improvement in the symptoms of knee pain by 4 months after delivery. Patellofemoral disorder presents as pain behind or around the patella, especially when going up and down stairs or with prolonged sitting [1]. Leg cramps which is a common presentation in pregnancy usually manifests in the second half of pregnancy has uncertain aetiology but is believed to be from the build-up of lactic and pyruvic acids resulting in involuntary muscle contraction [13]. They are generally experienced in the calves at night. Foot pain is significantly more common in pregnant women than in nonpregnant nulliparous women, selflimiting, resolving in less than four months [14]. Potential causes include weight gain, peripheral ligamentous laxity, and changes in posture and pedal pressure points [14]. Peripheral oedema is equally a notable cause of foot discomfort in pregnancy. Hand and wrist pains are commonly caused by carpal tunnel syndrome and de Quervain’s tenosynovitis. While the former is of neurological origin, the later occurs as a result of tenosynovitis of the abductor pollicis longus and extensor pollicis brevis tendons due to chronic overuse of the wrist and hand. De Quervain’s tenosynovitis (or de Quervain tenosynovitis) results from stenosing tenosynovitis of the first dorsal compartment of the wrist which contains the two tendons [15]. It presents as pain at the dorsolateral aspect of the wrist, with referral of pain toward the thumb and/or the lateral forearm. It is more common in the postpartum period where lifting the infant can cause the initial irritation [1]. Chest wall pain: There are no causes of musculoskeletal chest pain specific to pregnancy other than fractures of the ribs that may occur with the rare disorder ‘‘pregnancy associated osteoporosis” [16]. Chest wall changes that occur during pregnancy include increases in the subcostal angle, the anterior-posterior and transverse diameters of the chest wall, and the pregnancy is defined as pain localized below the line of the twelfth rib and above the inferior gluteal folds. It could present as axial or parasagittal discomfort in the lower back region. It is essentially musculoskeletal and may be due to a combination of mechanical, circulatory, hormonal, and psychosocial factors [2]. Low back pain is a common symptom in pregnancy and occurs in about 50-70% of pregnant women [2-4]. It is most prevalent in the second half of pregnancy. Risk factors include preexisting back pain, back pain in a previous pregnancy, advanced maternal age, and multiparity [4,5], while height, weight, race, fetal weight, and socioeconomic status do not appear to modify the risk [1]. A rare and undocumented cause of severe crampy low back pain in the early mid trimester of pregnancy has been experienced in relation to nephrolithiasis. The pain is episodic in nature, is usually aggravated by hard work or stress and is worse at night. The diagnosis is made from the discovery of renal stone in the kidney using ultrasonography. Treatment is conservative and involves microscopy, culture, and sensitivity studies of urine samples followed by treatment with relevant antibiotics, strong analgesics such as tramadol and the consumption of large volumes of water [6]. Pregnancy-related pelvic joint disorders including pubic symphysis separation, pelvic girdle pain, sacroiliac joint pain as well as pelvic girdle syndrome (pain in all the three pelvic joints) can arise during pregnancy following increased mobility and/or mechanical strain which can involve one or more of the pelvic joints. There is usually pubic symphysis separation of at least 2 mm to 3 mm during pregnancy from the normal 4 mm to 5 mm gap in the non-pregnant state. Symphysis diastasis is diagnosed based on the persistence of symptoms and a separation of more than 10 to 13 mm on imaging [7]. The risk factors for pubic symphysis diastasis are fetal macrosomia, precipitous labour, rapid second stage of labour, intense uterine contractions, previous pelvic pathology, trauma to the pelvic ring, multiparity, and forceps delivery [8]. While pain resolves in the majority of patients within a month, the pelvis usually returns to normal by 4 to 12 weeks postpartum [9]. Pelvic girdle pain (PGP) is sometimes classified under the broad category of low back pain [1]. It is a specific form of low back pain, with onset during pregnancy or the immediate postpartum period [10]. It is described as a stabbing pain in the buttocks distal and lateral to L5S1 which can radiate down to the knee, may be worse on weight bearing. It is related to nonoptimal stability of the pelvic girdle joints, hence pain in symphysis pubis, and/or unior bilateral pain in the sacroiliac joints are designated as PGP [10]. Risk factors include increased parity, previous low back pain, emotional stress, obesity, young maternal age, low educational level, early menarche, physically demanding work, and ISSN: 2572-3243 DOI: 10.23937/2572-3243.1510063 Adinma et al. J Musculoskelet Disord Treat 2018, 4:063 • Page 3 of 9 • to causes, consequences and treatment; presence of musculoskeletal disorders in the current or immediate past pregnancy. The social class of the respondents was derived from Olusanya classification which makes use of educational level of the woman and the occupation of her husband [18]. Data from the completed questionnaire were keyed into the system and analysed using SPSS version 17.0. Statistical relationships between variables were calculated using the Chi square test and a p-value of < 0.05 at 95% confidence interval was considered significant for all statistical comparison. The incidence of experience of musculoskeletal discomfort was expressed as discomfort respondent ratio (DRR). Discomfort respondent ratio measures the overall musculoskeletal discomfort experienced, as a proportion of number of the respondents, with respect to the biosocial variables. Analysed data were displayed in tables and chats.