Relationship between risk of locomotive syndrome and low back pain in Japanese postpartum women: a cross-sectional study

doi:10.21203/rs.3.rs-4147568/v1

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Relationship between risk of locomotive syndrome and low back pain in Japanese postpartum women: a cross-sectional study

https://doi.org/10.21203/rs.3.rs-4147568/v1

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Background

Pregnancy and childbirth lead to various physiological and anatomical changes, often resulting in low back pain and decline in physical activity in postpartum women. Locomotive syndrome is reportedly associated with low back pain and physical activity levels. However, the prevalence of locomotive syndrome and related factors in postpartum women have not been thoroughly investigated. Therefore, this study aimed to investigate the relationship between locomotive syndrome risk and low back pain and physical activity in postpartum women.

Methods

In this cross-sectional study, we included 86 women (30.0 ± 4.2 years) within 1 year postpartum. We assessed the locomotive syndrome risk using the stand-up test and 2-step test, physical activity using the International Physical Activity Questionnaire Short Form, and low back pain using the Oswestry Disability Index. The Oswestry Disability Index score and physical activity levels were compared between groups with and without the risk of locomotive syndrome.

Results

Overall, 45 women (52.3%) had a high risk of locomotive syndrome. The high-risk locomotive syndrome group had significantly higher Oswestry Disability Index [10 (0–26)] than the non-locomotive syndrome group [4 (0–24)] (p < 0.001). However, no significant difference was observed between the two groups in terms of age, number of births, or proportion of women with low physical activity levels.

Conclusions

The findings suggest that more than half of the women within 1 year after childbirth were at risk of locomotive syndrome, suggesting a relationship between locomotive syndrome and low back pain. Prevention of postnatal low back pain may necessitate addressing decline in prenatal motor function. The findings underscore the importance of early identification and intervention for locomotive syndrome risk in postpartum women to prevent future low back pain and improve mobility.

postpartum

locomotive syndrome

low back pain

physical activity

Pregnancy and childbirth can result in various physiological and anatomical changes, which may persist even after childbirth, thereby causing many physical symptoms such as low back pain (LBP) and muscle weakness [1–4]. LBP is a common symptom in prenatal and postpartum women, affecting approximately 50–80% of women during pregnancy [2–4]. While the symptoms may improve after childbirth in many women with LBP, a notable proportion (23%) of women with LBP during pregnancy remain symptomatic after childbirth, and 10% can develop LBP a decade later [5, 6]. LBP persists after childbirth and impairs activities of daily living (ADL) and quality of life [7]. Therefore, postpartum women should understand and address the condition of locomotive organs.

Exercise and physical activity (PA) are recommended for pregnant and postpartum women to reduce the risk of many pregnancy complications and promote overall health [8]. For example, the American College of Obstetrics and Gynecology (ACOG) recommends that women experiencing a healthy pregnancy should regularly engage in PA of moderate intensity for at least 20 to 30 min per day on most or all days of the week during pregnancy and the postpartum period [8]. Despite these recommendations, PA levels decrease in pregnant women [9, 10], with only 3% of women reaching the level of PA recommended by ACOG [11]. After childbirth, PA returns to the level undertaken in the second trimester; however, although light PA may increase, moderate- and high-intensity PA decrease. Postpartum women undertake less PA and are more sedentary compared to non-postpartum counterparts [1, 9, 10, 12].

Locomotive syndrome (LS) is a condition of reduced mobility due to impairment of locomotive organs, a concept proposed by the Japanese Orthopaedic Association (JOA) [13, 14]. LS is diagnosed using the following three modalities: the stand-up test, 2-step test, and 25-question geriatric locomotive function scale (GLFS-25). LS is reportedly associated with LBP and PA [15, 16]. A previous study reported that the prevalence of LS in young women was approximately 25% and that this prevalence increases concurrently with age [16]. In another study on nulliparous women in their 20s, only 43.6% of the participants met the reference values of the LS test score for Japanese women in their 20s [17, 18]. Therefore, LS poses a risk not only in older adults but also in young women. Postpartum women need to maintain adequate mobility for childcare and rehabilitation and for preventing future falls and fractures. However, despite the fact that LBP and decreased prenatal PA could increase the risk of LS, the prevalence of LS and related factors in postpartum women within 1 year after delivery have not been investigated. Therefore, this study aimed to investigate LS prevalence in postpartum women and clarify factors associated with LS risk including LBP. To our best knowledge, this is the first study to investigate LS in postpartum women.

Participants

In this cross-sectional study, the study participants were postpartum women who underwent childbirth within 1 year before enrollment. We recruited postpartum women at a local health event for pregnant and postpartum women in Aichi Prefecture, Japan, in February 2019. The inclusion criterion was an age > 20 years. We excluded pregnant women, women unable to understand the study explanation, and women with missing data. We explained our research aim and measurement items to the participants orally and in writing and obtained their written consent. Thereafter, the participants were asked to complete questionnaires and perform the LS risk tests (stand-up test and 2-step test), and their body composition was measured. Our questionnaire consisted of items on demographic data (age, height, weight, the period from the last birth, and number of births), the International Physical Activity Questionnaire Short Form (IPAQ-SF), and the Oswestry Disability Index (ODI) for assessing LBP assessment. All assessments were performed at the event venue where recruitment was conducted.

LS risk test

The main outcomes were the 2-step and stand-up test scores, which reflected the participants’ physical function. These tests were used to assess LS risk. The 2-step test involves measuring stride length in two steps. The participants were instructed to take two steps, each step as long as possible, and the measurement was recorded (Fig. 1). The 2-step test score was used to classify the LS risk level and was calculated using the following formula: length of the two steps (cm)/height (cm). In the stand-up test, the height of the lowest stool from which the participant could stand up from a sitting position using two legs or one leg was recorded. Stools of 40 cm and 20 cm heights were used. The participant was considered to have completed the trial if they succeeded in holding the final standing position for longer than 3 s without requiring any additional steps (Fig. 2). The criteria for LS Stage 2 were a 2-step test score < 1.1 or difficulty rising on both legs from a 20 cm-high stool in the stand-up test. The criteria for LS Stage 1 were a 2-step test score < 1.3 or difficulty rising on one leg from a 40 cm-high stool in the stand-up test (either leg) but the ability to rise on both legs from a 20 cm-high stool.

Customarily, the LS test also includes the GLFS-25, a questionnaire focused on body pain and ADL in the most recent month. However, we did not administer this questionnaire in the present study, as it was originally developed for older people. A previous study revealed that the interquartile range of the GLFS-25 score was lower in women in their 20s and 30s than the cut-off points of LS Stage 1 [18].

Body composition

Appendicular skeletal muscle mass (ASM) was measured using bioelectrical impedance analysis with a body composition analyzer (MC-780A, TANITA, Tokyo, Japan), and the skeletal muscle mass index (SMI; ASM [kg]/height² [m]) was calculated as an index of body composition. Body fat percentage and body mass index (BMI) were used as additional indices.

PA

The IPAQ-SF Japanese version is a valid and reliable assessment tool for PA [19]. The IPAQ-SF includes the frequency and duration (at least 10 min) of PA of high, moderate, and low intensity in a usual week and sedentary time during a typical day. PA level below 600 metabolic equivalent (MET) min/week was categorized as low PA, and that of more than 600 MET min/week was categorized as moderate and high PA. In addition, sedentary time in the IPAQ-SF was used as an index of inactivity.

LBP

The ODI is a disease-specific self-report outcome tool used to measure functional disability related to LBP [20], and the reliability and validity of the Japanese version have been reported [21]. The ODI consists of the following 10 items: pain intensity, personal care, lifting, walking, sitting, standing, sleeping, sex life, social functioning, and traveling. For each item, the participant rates the level of disability on a scale from 0 to 5. The final score is calculated as follows: (total score) ×100 / (5 × number of items answered). Scores range from 0 (no disability) to 100 (most severe disability). The cut-off value for functional disability due to LBP was set to 12 points based on a previous study [22].

Statistical analyses

Participants who met the criteria for LS Stage 1 or 2 in either the 2-step or stand-up test were classified as the high-risk LS group, whereas those who did not were classified as the non-LS group. The Mann–Whitney U test was used to compare continuous data between the high-risk LS and non-LS groups. Categorical data are presented as number (percentage) and were assessed using the chi-square test. A P-value < .05 was considered significant. All analyses in this study were performed using IBM SPSS Statistics ver. 28 (IBM Corp, Armonk, NY, USA).

In this study, we initially recruited 102 postpartum women, of whom 16 were excluded because of missing data (unanswered questionnaire items). The remaining 86 women were divided into the high-risk LS and non-LS groups (Fig. 3. The mean age of all the participants was 30.0 ± 4.2 years, and 52.3% of the women had a high risk of LS. In the stand-up test, all 13 women who met the criteria for LS could stand up on both legs from a 20 cm-high stool and were classified as having LS Stage 1, and none of them were classified as having LS Stage 2. In the 2-step test, 30 women had a 2-step score < 1.3 (LS Stage 1), and three women had a 2-step score < 1.1 (LS Stage 2). Only one woman was at risk in both the stand-up and 2-step tests.

The high-risk LS group had a significantly higher ODI than did the non-LS group. However, no significant difference was observed between the two groups in terms of age, BMI, the period from the last birth, number of births, low PA, sedentary time, SMI, and body fat percentage (Table 1). Comparing the subscale of the ODI between the two groups, the high-risk LS group had a significantly higher score for pain intensity and sitting (Table 2).

Table 1

Characteristics of postnatal women with and without a high risk of locomotive syndrome
	Overall (n = 86)	High-risk LS group (n = 45)	Non-LS group (n = 41)	p-value
Age (years)	30 (21–40)	31 (21–40)	28 (25–39)	0.11
Body mass index (kg/m²)	20.1 (15.8–34.6)	20.3 (17.2–34.6)	19.9 (15.8–25)	0.22
Period since the last birth (months)	7 (1–11)	7 (1–10)	7 (2–11)	0.22
Number of births (number)				0.66
1	58 (67.4)	32 (71.1)	26 (63.4)
2	23 (26.7)	10 (22.2)	13 (31.7)
3	5 (5.8)	3 (6.7)	2 (4.9)
ODI score (%)	7.5 (0–26)	10 (0–26)	4 (0–24)	< 0.001
Low physical activity (number)	53 (61.6)	26 (57.8)	27 (65.8)	0.44
Sedentary time (min/day)	240 (30–1140)	225 (30–1140)	240 (60–900)	0.71
Skeletal muscle mass index (kg/m²)	6.7 (5.6–8.7)	6.7 (5.9–8.7)	6.7 (5.6–7.5)	0.81
Body fat percentage (%)	25.9 (12.9–48.6)	26.2 (17–48.6)	25.2 (12.9–35.8)	0.27
Stand-up test (number)	14 (16.2)	14 (31.1)	0 (0.0)	< 0.001
2-step test (number)	33 (38.4)	33 (73.3)	0 (0.0)	< 0.001
2-step test score	1.3 (1.0–1.5)	1.2 (1.0–1.5)	1.4 (1.3–1.5)	< 0.001
LS: Locomotive syndrome, ODI: Oswestry Disability Index; Mann–Whitney U test, median (range): age, BMI, period from the last birth, ODI score, sedentary time, skeletal muscle mass index, body fat percentage, 2-step test score; Chi-square test, n (%): the number of births, low physical activity, and stand-up test

Table 2

Subscale ODI score in postnatal women with and without a high risk of locomotive syndrome
	Overall (n = 86)	High-risk LS group (n = 45)	Non-LS group (n = 41)	p-value
Pain intensity	1 (0–4)	1 (0–4)	1 (0–3)	0.03
Personal care	0 (0–1)	0 (0–1)	0 (0–1)	0.74
Lifting	0 (0–2)	1 (0–2)	0 (0–2)	0.06
Walking	0 (0–1)	0 (0–1)	0 (0–1)	0.20
Sitting	1 (0–2)	1 (0–2)	0 (0–2)	0.02
Standing	1 (0–2)	1 (0–2)	0 (0–2)	0.09
Sleeping	0 (0–2)	0 (0–2)	0 (0–2)	0.33
Sex life	0 (0–5) (n = 71)	0 (0–5) (n = 33)	0 (0–1) (n = 38)	0.27
Social life	0 (0–2) (n = 82)	0 (0–2) (n = 40)	0 (0–1) (n = 42)	0.41
Traveling	0 (0–4)	0 (0–4)	0 (0–1)	0.09
ODI: Oswestry Disability Index, LS: Locomotive syndrome
Mann–Whitney U test, median (range)

In this study, we investigated prevalence of LS and explored factors associated with LS risk in postpartum women. We found that 52.3% of postpartum women within 1 year after childbirth had a high risk of LS, which is approximately twice the proportion of non-pregnant women in their 20s (24.5%) and 30s (26.5%) and close to the proportion of those in their 60s (53.5%) [23]. This underscores the increased likelihood of impaired mobility in postpartum women compared with that in other counterpart women of the same age.

Many intervention studies aimed at improving LS have been conducted. Notably, studies on electrical muscle stimulation of the quadriceps in older women [24] and hip flexor muscle strengthening [25] have shown improvements in the 2-step test scores. Similarly, a study on middle-aged individuals who performed squats and open-eyed single-legged standing revealed improvements in the stand-up test score [26]. Furthermore, a study conducted among older women who exercised their trunk muscles using training equipment showed improvements in both the 2-step and stand-up test scores [27]. In the present study, 38.4% and 16.2% of the participants were classified as LS based on the 2-step and stand-up test, respectively, and only one participant met the criteria based on both tests. Although no significant difference was noted in the SMI, it may be possible to improve LS by changing the approach depending on which LS test’s criteria are met.

In the present study, only LBP was associated with LS risk. Previous studies targeting young and middle adulthood have revealed that LBP is related to LS [15, 16], suggesting LBP as a potential risk factor for LS, even in postpartum women. In terms of ADL, we suggested that the high-risk LS group was more significantly affected by pain than was the non-LS group, especially in the sitting position. In the stand-up test, starting from a sitting position might be influenced by LBP, potentially impacting the test results. A previous study has shown that the strength of the hip muscles, including the abductors and extensors, is decreased in individuals with non-specific chronic LBP [28]. These muscles are important for standing up or taking longer strides. In the present study, we did not examine the hip muscle strength; nonetheless, some participants with LBP might have had weakened hip muscles, which may have contributed to the LS risk.

However, some participants with LS did not have LBP at the time of measurement. van Benten et al. reported that single-leg standing balance was reduced despite self-reported resolution of pregnancy-related pelvic girdle pain [29]. This suggests that even after having recovered from pelvic pain in the postpartum period, women may have difficulty in rising on one leg from a 40 cm-high stool or their maximum stride length may be reduced due to decline in their balance function, which may lead to LS.

Although moderate-to-high PA levels were associated with a lower LS risk, we found no significant difference in PA levels between the high-risk LS and non-LS groups. Regarding PA, 61.6% of the women in this study had low PA levels, despite the ACOG recommendation for postpartum women [8]. In the non-LS group, 57% of the participants had a low PA level. Therefore, no significant difference was noted between the two groups in terms of PA levels. Most pregnant women decrease their PA levels throughout pregnancy [9, 10], and PA levels remain low after giving birth [1, 9, 10, 12]. Based on a previous study that identified determinants of changes in PA across the transition period to parenthood [30], possible barriers to postpartum PA include limited time owing to childcare or other tasks and physical difficulties such as pelvic floor disorder. Pelvic floor disorder is a common postpartum symptom, and many postpartum women experience urinary incontinence. Pelvic floor symptoms are considered a barrier to exercise participation [31]. However, provision of accurate information from a medical professional can facilitate PA during pregnancy and after childbirth. Therefore, medical professionals, including obstetricians, midwives, and physiotherapists, should develop approaches to increase PA of pregnant and postpartum women. In particular, it may be difficult for postpartum women to balance childcare responsibilities and find time for exercise. In this study, no significant relationship was observed between LS risk and PA levels; however, the PA of mothers with children should be increased, as most women have low PA levels after childbirth.

This study has several limitations. First, the study design was cross-sectional, and the causal relationship between LS risk and LBP is unknown. Second, we did not obtain GLFS-25 data; therefore, the results of only few previous studies can be compared to those of our study. Third, the participants were recruited at a local health event, potentially excluding women with severe LBP. Finally, the JOA revised the clinical decision limits and introduced a new LS stage, Stage 3, in 2020 [32]; there were only two stages when we conducted this survey in 2018. Hence, the highest stage in this report was Stage 2. However, the present study indicates that decreased locomotive function before or during pregnancy may be a contributing factor to LBP. Medical professionals, including obstetricians, midwives, and physiotherapists, should be vigilant in assessing LS risk among postpartum women and provide appropriate interventions to promote mobility and overall health. Further validation, including intervention studies to prevent the decline in locomotive function before pregnancy as this may prevent LBP after childbirth, is needed.

This study demonstrated that 52.3% of postpartum women within 1 year after childbirth were at risk of LS, suggesting a relationship between LS risk and LBP. The high prevalence of LS among postpartum women underscores the importance of early detection and intervention strategies to prevent or mitigate LS-related impairments in mobility. Future research should focus on longitudinal studies to establish causality between LBP and LS risk in postpartum women.

LBP

low back pain

ADL

activities of daily living

physical activity

ACOG

the American College of Obstetrics and Gynecology

locomotive syndrome

JOA

the Japanese Orthopaedic Association

GLFS-25

the 25-question geriatric locomotive function scale

IPAQ-SF

International Physical Activity Questionnaire Short Form

ODI

Oswestry Disability Index

ASM

appendicular skeletal muscle mass

SMI

skeletal muscle mass index

BMI

body mass index

IPAQ-SF, International Physical Activity Questionnaire Short Form

MET, metabolic equivalent

Ethics approval and consent to participate

Written informed consent was obtained from each participant per the guidelines approved by the Research Ethics Committee and the Declaration of Human Rights (Helsinki, 1975). The study protocol was approved by the Research Ethics Committees of Kyoto University (approval number R1840) and Kio University (approval number R1-01).

Consent for publication

Written informed consent for use was obtained from the model in the pictures.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

Not applicable.

Authors’ contributions

YK, DM, and TI proposed the research ideas, and YK, DM, TI, MT, and TA designed the study. YK, DM, TI, and RK carried out the studies and drafted the manuscript. MT and TA revised the manuscript. All authors have read and approved the final manuscript.

Acknowledgements

The authors are especially grateful to all the participants for their willingness to participate in the study. We thank the staff of “HAPPY MAMA FESTA” for assisting with this study. We are also grateful to the members of Kio University, Kyoto University, and Nagoya University for their helpful suggestions and their help carrying out the measurements.

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No competing interests reported.

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Relationship between risk of locomotive syndrome and low back pain in Japanese postpartum women: a cross-sectional study

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Abstract

Background

Methods

Results

Conclusions

Figures

Background

Methods

Participants

LS risk test

Body composition

PA

LBP

Statistical analyses

Results

Discussion

Conclusion

Abbreviations

Declarations

References

Additional Declarations

Status:

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