Systematic Review of Non-Pharmacological Treatments for Pregnancy Back Pain

A systematic review and meta-analysis of the effectiveness of therapeutic exercise and acupuncture for the treatment of low back pain in pregnancy

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Aims and Objectives (200 words)

Aim of the research :

Aim of this research includes carry out a systematic review and meta-analysis of the effectiveness of therapeutic exercise and acupuncture for the treatment of low back pain in pregnancy

The objectives for this study will be as follows:

1. To carry out a cursory search of the literature for background information on therapeutic exercise and acupuncture for the treatment of low back pain in pregnancy
2. To justify the need for the SR and meta-analysis
3. To design a search strategy for identifying critical information on the research area (to include keywords, databases, inclusion/exclusion criteria for the SR)
4. To acquire ethical approval
5. To carry out the searches and retrieve all studies published that meet the inclusion criteria for the SR.
6. To analyse the studies and identify key findings
7. To export data from the studies in the SR into meta-analysis software
8. To carry out a meta-analysis of the data
9. To identify key statistical findings of the meta-analysis
10. To discuss the main findings of the SR and meta-analysis
11. To make clinical recommendations for therapeutic exercise and acupuncture for the treatment of low back pain in pregnancy

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Background (500 words)

Low back pain is a common problem for pregnant women due to the body's physical changes. There is a valid reason behind the low back pain of women during pregnancy. It is due to the continuous growth of the uterine region and to avoid leaning forward mother leans backwards to make balance her body posture (AP et al. 2020). The current project is focused on the evaluation of therapeutic exercise and the effectiveness of acupuncture for the treatment of low back pain in pregnant women. However, it has been evaluated that the use of therapeutic exercise and acupuncture is better than the use of medicine and drug to reduce low back pain among pregnant women. Most pregnant women select medications to relieve lower back pain; however, it may produce a harmful effect on a child who is growing in womb (Larson et al., 2019). The reason behind it, nowadays, painkillers and drugs are available in the market for low back pain reduction and physicians also prescribe for instant low back pain reduction, which has several side effects. Therefore, in current days, regarding health consciousness and safety pregnant women are going for acupuncture and treatment.

Lower back pain during the time of pregnancy is the most common and natural problem of pregnant mothers. The reason behind it is the physiological changes in the body of pregnant women. However, it is found that when a child begins to grow and the uterine cavity of the pregnant mother increases due to the increase of amniotic fluid (Wuet al. 2019). Therefore, the lower abdomen region of pregnant women becomes growing and the centre of gravity of the mother’s body started to shift forward. Therefore, pregnant mothers naturally start to lean back to avoid falling or leaning forward (de Sousa et al. 2019). It creates a strain on the back muscle of pregnant women, which started to create lower back pain in pregnant women. Therefore, the doctor advises mothers to use therapeutic exercise and, if not cured, acupuncture and try to avoid medication. Excessive use of painkillers and other medicines and drugs harms the foetus directly. There are two kinds of treatment generally taken by pregnant women to relieve lower back pain. One is medication by in taking painkillers every day during pregnancy and another is acupuncture and therapeutic exercise.

As advised by most doctors medication has lots of side effects on the foetus and the health of the mother. Excessive intake of painkillers can create chronic heart disease in the mother. Acupuncture is a traditional Chinese treatment where an acupuncturist inserts needles into the major acupoints of the body (Nicolian et al., 2019). According to the acupuncturist, there are 14 major acupoints or meridians present in the human body that are called “energy-carring channels” among which GV-20, GB-34, SI3, BL-57, LR-3, ST 36 and LI-4 are used to treat back pain (Citkoet al. 2018). After stitching needles into the acupoints, the human body naturally starts to release endorphins, which are a natural pain killer and neurotransmitter of the human body that help to control natural nerve impulses and helps to rebalance the body.

As mentioned by health professionals, acupuncture has minimum side effects when its performed by a qualified and professional acupuncturist. There are thousands of successful acupuncture treatment is taken by pregnant mothers every day all over the world. There is a complete lack of knowledge and awareness about the treatment of acupuncture in the current world. However, it is found that a large number of harmful effects of using painkillers and drugs during pregnancy. However, it harms both mother and the foetus. As mentioned by Saptyani et al. (2020), there are lots of side effects to the use of painkillers and drugs to reduce LBP during pregnancy. Therefore, worldwide awareness generation is required by the help of international agencies like WHO and other organisations.

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Critical Evaluation of one key paper (1500 words)

Selected article: Martins, E.S., Tavares, T.M.C.L., Lessa, P.R.A., Aquino, P.D.S., Castro, R.C.M.B. and Pinheiro, A.K.B., 2018. Acupuncture treatment: multidimensional assessment of low back pain in pregnant women. Revista da Escola de Enfermagem da USP, 52.

Article introduction

This article mainly aims for evaluating the acupuncture process and its effectiveness for treating pregnant women that are in their second and third trimesters. The women selected as the participant for the research are mainly between 14-37 weeks of gestational periods. The women all are suffering from the low back pains and complaints to their doctors. As therapeutic measure, in certain woman, acupuncture has been selected. For pain accessing process, McGuill questionnaire has been developed. The process is also associated with other research instruments for acquiring social, demographical, obstetrics and clinical information. A method of quasi-experimental design of pre-post has been applied for this research. A total of 56 participants in the research have been included. Six session of acupuncture has been performed for the participants, and analysis of their pain level has been done. The statistical analysis of pain level reduction, positive impact on health against the acupuncture sessions and gradual improvement has been observed. Also, adverse effects for the process have also analysed, and the result is negative.

Low back pain in pregnant women

The low back is very common for any pregnant woman. As stated by Martins et al. (2018) Low back pain mainly occurs between the 12th rib and the gluteal fold. During the early stage of pregnancy, the ligaments of the joints become soft because the body is preparing for the stretch in labor pain. So, the strain on the joints of the lower back for the pregnant woman is common. However, as stated by Manyozo (2019) if this low back pain for the pregnant woman lasts for more than two weeks or becomes severe then it is subject to concern. It is advised to contact a personal physician or general physician. It has been seen that the prevalence of lower back pain is around 50% and 20% among pregnant women with low back pain needs proper medical management.

It has been seen that pregnant women with low back pain are ignored by the healthcare profession and are also a subject of lack of attention. According to Martins et al. (2018), pregnancy-related low back pain has been overlooked in some countries of the world and it has also been reported that this disease of pregnant women is sometimes overlooked by physicians. There are many arguments about taking low back pain more seriously and giving this disorder a proper entitlement to be a disease that should be a concern for the doctor (Beyeraet al. 2019). However, Some physicians think this disorder should not be entitled as a disease then it will be used as a sickness benefit. This has also been one of the reasons for the increased prevalence of lower back pain Shiri et al. (2019). Low back pain is also associated with other disorders such as disruption of social and sexual life, disruption of health; decrease in work capacity, and also with increased psychological stress and other disorders.

The harmful effect of the medication

As mentioned by Martins et al. (2022), there are lots of side effects of excessive use of painkillers and drugs to reduce lower back pain both in pregnant mothers and foetuses. A report found that thousands of women all over the world use opioids and NSAIDs painkillers to reduce pain during pregnancy. Therefore, lots of birth defects arose during the time of delivery, which causes lots of casualties and accidents (Mascarenhas et al., 2022). Thousands of babies and mothers die during the time of delivery due to the excessive use of opium and NSAIDs.

There is some common analgesics are used as a painkiller for LBP during pregnancy, they are “Acetaminophen, Aspirin, Non-steroidal anti-inflammatory drugs or NSAIDs and opioids". Every pain killers have their side effects (Martins et al., 2022). Therefore, the patients are required to go to the doctors for consultation and should use painkillers according to the prescriptions of the doctor. Excessive use of painkillers can create “Spina Bifida, cleft palate and gastroschisis" in child.

As mentioned by Hu et al. (2020), therapeutic exercise is highly effective for lowering LBP in pregnant women. However, it found that “an exercise program of 8 to 12 weeks can reduce the LBP of pregnant women by almost 44%” (Martins et al., 2022). There is a lack of awareness of using therapeutic treatment for LBP by pregnant women all over the world.

Therefore, the doctors advised pregnant women to use therapeutic exercise and acupuncture in place of excessive medication and use analgesics and opioids.

Therefore, the current project aims to create mass awareness about the alternative treatment of lower back pain during pregnancy for pregnant women. Therapeutic exercise and acupuncture is the best treatment for LBP because this is no or fewer side effects of this kind of treatment and it is good for the health and future of both mother and baby.

Effect of acupuncture in diminishing pregnant woman's low back pain

Low back pain is a common disease, especially for women in their mid-thirties or forties and it can be treated easily by using some of the easy-to-prescribe drugs. However according to Martins et. al. (2018) for the pregnant woman if the low back pain occurs then it has been observed more delicately, and precisely and has limited therapeutic options because this medication will affect the mother as well as the fetus. Two lives become the subject of concern for this pregnant woman so the pregnant women will be needed to handle it in a more gentle and humanized way. These medicines might have limitations or possible side effects for the mother and the fetus. All these reasons have increased the demand for other alternate and complementary methods. Acupuncture procedures are often used for the treatment of lower back pain in pregnant women Shiri et al. (2019). Acupuncture is a traditional Chinese and Indian therapy that promotes better healing by blood flow and stimulation and increases the quality of life.

There are many positive results of using the acupuncture procedure for lower back pain. Acupuncture is a new useful alternative to or complements the “traditional analgesic pain relief” for low back pain. 87% of pregnant low-back pain patients were found to reduce the pain more effectively with minimal side effects. There are many national and international guidelines available for pregnant women and also promoted the guidelines by the WHO. This physical activity can help to reduce the risk factor of pregnancy and also increases fitness and improves the quality of life for pregnant women (Martins et al. 2022). In 2008 physical activity was first recommended for pregnant women by a newly published article. After that, some articles were also published in this regard and that also showed the importance of physical exercise for pregnant women. All these articles have proved that articles can reduce the chance of lower back pain. It has also been seen that acupuncture reduces low back pain more effectively for pregnant women rather than physiotherapy or medications. It has not been studied properly and the mechanism of action for this disease is not clear. However, as stated by Martins et. al. (2018) the somatic and autonomic systems and the neuroendocrine system are plays a vital role in the acupuncture procedure.

Cost-effectiveness of acupuncture

The traditional treatment for low back pain analgesics has affected negatively the pregnant woman. Low back pain has a disabling effect because it disables the daily working activity of the pregnant woman. However, sometimes low back pain goes untreated in pregnant women although there is disabling effect. The main cause of low back pain during pregnancy has not been clearly understood by the physician or did not try enough to understand it (Martins et al. 2018). Often this disorder is considered a natural disease that is associated with biochemical, vascular, and hormonal changes during pregnancy. NSAIDs and analgesics are medications that have been used traditionally but in recent times it has been found that these medications have many side effects and the treatment of these medications has not been satisfactory for the pregnant woman. For all these factors stabilization exercises and physical activities are considered the first line of management for the treatment of this disease.

Physical exercise does not require so much money for the treatment as it is required for the treatment of the disease traditional way. Also with that acupuncture is a very cost-effective procedure which also can be a big advantage against the treatment of taking the drug medication. So, acupuncture treatment and physical activity are much more cost-effective than medication and it is a more effective way the treatment of low back pain in a pregnant woman (Martins et al. 2018). However, other non-pharmacological approaches such are interdisciplinary rehabilitation, spinal manipulation, cognitive behavior, and others compared to that acupuncture and physical exercise are more easily accessible and can be used as a part of the self-management strategy which is required less equipment and can be performed at home.

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Justification (500 words)

Low back pain is now one of the major problems during the gestational period. This low back pain especially can be seen in pregnant women as increasing weight is one of the major reasons for it. Low back pain causes discomfort in the back of the pregnant women which will lead to irritation if it gets more severe or if it continued for more than 2 weeks then it becomes the subject of concern in case of pregnant women (Gutke et al. 2018). Low back pain is often noticed in pregnant women at the early stages of gestation. If this problem goes untreated for many days then it can affect the spinal cord. For the pregnant woman, it can harm the fetus as well as the mother. Therefore mortality rate increases not only for foetus but also for mothers. It is one of the major problems in current days because people are involved in fewer physical activities compared to previous days (Hu et al. 2020). However, reduce workload at house and more sedentary lifestyle makes people overweight and obese which can be a factor in low back pain in pregnant women. The amount of walking or doing any physical work has been reduced in the current days, which is leading to this many complications for the pregnant women (Larson et al. 2019). These factors also increase the chance of low back pain.

The traditional use of analgesics for lower back pain relief has now had a lower effect on the pregnant women. Pregnant women are now getting more resistant to lower back pain which causes them to take more powerful medication, which also has many side effects. For pregnant women, it becomes a major issue because the side effects of these analgesics are huge and can harm the pregnant woman as well as the fetus. It has been seen that almost 50% of pregnant women go through low back pain and among that 20% of them are goes through the proper medication rather the physical activity or acupuncture (Manyozo, 2019). Also, 25% of pregnant pregnant women are continued to experience lower back pain after 1 year after delivery (Weiset al. 2018). There are many studies that support this statement. It has also been seen that 87% of pregnant women with low back pain are getting the treatment with the acupuncture procedure and physical activity which also shows the result regarding that (Gutkeet al. 2018). Therefore, this research result will help in identification of advantages of acupuncture point and therapeutic exercise effect with low side effects in respect to pregnant women.

This research will shed light on the effectiveness of physical activity for low back pain in pregnant women also with that the effectiveness of acupuncture procedures for the treatment of low back pain pregnant women (Manyozo, S., 2019). In addition to that, the outcome of this research will benefit most pregnant women with low back pain. Also, this research will help normal people with low back pain to understand the effectiveness of physical activity for this disease, and with that also the effectiveness of the traditional acupuncture procedure.

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Ethics (100 words)

The data protection act will be considered for this research work. The data protection act helps in the protection of research data from unauthorized access before publication. Henceforth, the application of the data protection act will help protect systematic research findings from unauthorized access (Wachter et al. 2019). Moreover, in order to conduct the research University consent will be collected to avoid ethical issues regarding conducting research. Primary participants of pregnant women will not be included in the systematic review study however; the primary articles will be taken into account. Hence there are no human participants are added for this research. The data protection act will help in protecting the information of the participants based on which primary articles have been published.

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Main Method (650 words)

Literature search methods

Search strategy

Search engine Google scholar, Pubmed, CINAHL and ProQuest will be considered to collect the articles related to the acupuncture effect on low back pain for pregnant women. As stated by Gusenbauer et. al. (2020) the database of Google scholar is huge and many articles' information can be retrieved from Google scholar. So this search engine will be considered to achieve the project objectives. Also, ProQuest consists of a huge database from which topic-related articles. Moreover, these search engines are government certified therefore, the relevancy and accuracy of the collected articles will be high. Additionally, Cochrane and PubMed will be considered to collect the medical information related to articles. Primary articles will be taken into account for this systematic review.

Keywords that will be going to consider here are therapeutic exercise, RCT, systematic review, primary research meta-analysis, acupuncture, low back pain, and pregnancy. These keywords will increase the accuracy of the search which is why these keywords will be used (Xu et al. 2019). Identification of keywords also will be helpful in the reduction of the number of search results related to the impact of low back pain, pregnancy, and Boolean operators which will be used for this proposal are AND or NOT. These operators will help to separate the search result from undesired ones. The search engines that will be used here have a huge database. So, syntax will be formed using these keywords and Boolean operators, which will help to do the search for the systematic review process on the topic of the effectiveness of therapeutic exercise and acupuncture for pregnant women's low back pain more accurately and separately from that huge database.

Inclusion and exclusion criteria

Feature	Inclusion criteria	Exclusion criteria
Publication year	Last 10 years	Before the last 10 years
Full text version	Available online	Not available
Peer reviewed	Non-Peer Reviewed
Topic related	Low back pain Pregnant woman Acupuncture treatment	Other diseases. Normal-aged woman. Other treatment.
Language	English	Dutch English, Portuguese and others

Table 1:Inclusion and exclusion criteria

(Source: Self-developed)

These criteria for inclusion and exclusion for any article will be considered for filtering the proper articles for the systematic review process on the topic of the effectiveness of therapeutic exercise and acupuncture for pregnant women’s low back pain.

Screening of articles

PRISMA will be used in order to reduce the duplicity of the articles selected. As stated by Page et. al. (2021), PRISMA is utilized to remove the irrelevant in duplicate articles. Therefore, considering this to screen articles will be helpful to increase the accuracy and quality of results obtained from the systematic review process on the topic of the effectiveness of therapeutic exercise and acupuncture for pregnant women’s low back pain. PRISMA will help in stating the reason behind rejecting articles and the inclusion of a specific number of articles. Total 10 articles will be taken into account to produce a review on the effect of acupuncture and therapeutic exercise in lowering back pain intensity.

Systematic review method

The systematic review method has been considered which is less time-consuming and cost-effective (Munn et al. 2018). Search characteristics will be developed in a tabular form in which the aim, objectives, method, and conclusion will be considered. Aim, objectives, methodology, and findings will be taken into account from every topic-related article, which is primary. Thematic analysis will be used to separate the search for a systematic review on the topic of the effectiveness of therapeutic exercise and acupuncture for pregnant women's low back pain using proper search characteristics.

CASP tools will be used to analyze the quality of the articles selected for the articles. CASP score will help in understanding the quality of the selected primary articles based on aim, objective, methodology, and result. CASP is beneficial for the quality appraisal of the considered articles (Long et al. 2019). Data will be extracted from each article and will be represented in a tabular format which will help in depicting the information that will be incorporated into the result.

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Key References (max 15 for the whole document)

AP, F.C., Dufresne, S.S., Rogerio de Oliveira, M., Dubois, M., Dallaire, M., Ngomo, S. and Da Silva, R.A., 2020. Effects of lumbar stabilization and muscular stretching on pain, disabilities, postural control and muscle activation in pregnant woman with low back pain. European journal of physical and rehabilitation medicine, 56(3), pp.297-306.

Beyera, G.K., O’Brien, J. and Campbell, S., 2019. Health-care utilisation for low back pain: a systematic review and meta-analysis of population-based observational studies. Rheumatology international, 39(10), pp.1663-1679.

Citko, A., Górski, S., Marcinowicz, L. and Górska, A., 2018. Sedentary lifestyle and nonspecific low back pain in medical personnel in North-East Poland. BioMed research international, 2018.

de Sousa, V.P.S., Cury, A., Eufrásio, L.S., de Sousa, S.E.S., Coe, C.B. and de Souza Ramalho Viana, E., 2019. The influence of gestational trimester, physical activity practice and weight gain on the low back and pelvic pain intensity in low risk pregnant women. Journal of Back and Musculoskeletal Rehabilitation, 32(5), pp.671-676.

Gusenbauer, M. and Haddaway, N.R., 2020. Which academic search systems are suitable for systematic reviews or meta?analyses? Evaluating retrieval qualities of Google Scholar, PubMed, and 26 other resources. Research synthesis methods, 11(2), pp.181-217.

Gutke, A., Boissonnault, J., Brook, G. and Stuge, B., 2018. The severity and impact of pelvic girdle pain and low-back pain in pregnancy: a multinational study. Journal of women's health, 27(4), pp.510-517.

Gutke, A., Boissonnault, J., Brook, G. and Stuge, B., 2018. The severity and impact of pelvic girdle pain and low-back pain in pregnancy: a multinational study. Journal of women's health, 27(4), pp.510-517.

Hu, X., Ma, M., Zhao, X., Sun, W., Liu, Y., Zheng, Z. and Xu, L., 2020. Effects of exercise therapy for pregnancy-related low back pain and pelvic pain: A protocol for systematic review and meta-analysis. Medicine, 99(3).

Larson, J.J., Graham, D.L., Singer, L.T., Beckwith, A.M., Terplan, M., Davis, J.M., Martinez, J. and Bada, H.S., 2019. Cognitive and behavioural impact on children exposed to opioids during pregnancy. Pediatrics, 144(2).

Long, H.A., French, D.P. and Brooks, J.M., 2020. Optimising the value of the critical appraisal skills programme (CASP) tool for quality appraisal in qualitative evidence synthesis. Research Methods in Medicine & Health Sciences, 1(1), pp.31-42.

Manyozo, S., 2019. Low back pain during pregnancy: Prevalence, risk factors and association with daily activities among pregnant women in urban Blantyre, Malawi. Malawi Medical Journal, 31(1), pp.71-76.

Martins, E.S., Tavares, T.M.C.L., Lessa, P.R.A., Aquino, P.D.S., Castro, R.C.M.B. and Pinheiro, A.K.B., 2018. Acupuncture treatment: multidimensional assessment of low back pain in pregnant women. Revista da Escola de Enfermagem da USP, 52.

Mascarenhas, V.H.A., Caroci-Becker, A. and Riesco, M.L., 2022. Effectiveness of aromatherapy versus standard care on physiological and psychological symptoms in pregnant women: a systematic review protocol. JBI Evidence Synthesis, 20(2), pp.658-665.

Munn, Z., Peters, M.D., Stern, C., Tufanaru, C., McArthur, A. and Aromataris, E., 2018. Systematic review or scoping review? Guidance for authors when choosing between a systematic or scoping review approach. BMC medical research methodology, 18(1), pp.1-7.

Nicolian, S., Butel, T., Gambotti, L., Durand, M., Filipovic-Pierucci, A., Mallet, A., Kone, M., Durand-Zaleski, I. and Dommergues, M., 2019. Cost-effectiveness of acupuncture versus standard care for pelvic and low back pain in pregnancy: a randomized controlled trial. PloS one, 14(4), p.e0214195.

Page, M.J., McKenzie, J.E., Bossuyt, P.M., Boutron, I., Hoffmann, T.C., Mulrow, C.D., Shamseer, L., Tetzlaff, J.M. and Moher, D., 2021. Updating guidance for reporting systematic reviews: development of the PRISMA 2020 statement. Journal of clinical epidemiology, 134, pp.103-112.

Saptyani, P.M., Suwondo, A. and Runjati, R., 2020. Utilization of Back Movement Technique to Intensity of Low Back Pain in Third Trimester Pregnant Women. STRADA Jurnal Ilmiah Kesehatan, 9(2), pp.535-542.

Shipton, E.A., 2018. Physical therapy approaches in the treatment of low back pain. Pain and therapy, 7(2), pp.127-137.

Shiri, R., Coggon, D. and Falah?Hassani, K., 2018. Exercise for the prevention of low back and pelvic girdle pain in pregnancy: A meta?analysis of randomized controlled trials. European Journal of Pain, 22(1), pp.19-27.

Vas, J., Cintado, M.C., Aranda?Regules, J.M., Aguilar, I. and Rivas Ruiz, F., 2019. Effect of ear acupuncture on pregnancy?related pain in the lower back and posterior pelvic girdle: A multicenter randomized clinical trial. Acta obstetricia et gynecologica Scandinavica, 98(10), pp.1307-1317.

Wachter, S. and Mittelstadt, B., 2019. A right to reasonable inferences: re-thinking data protection law in the age of big data and AI. Colum. Bus. L. Rev., p.494.

Weis, C.A., Barrett, J., Tavares, P., Draper, C., Ngo, K., Leung, J., Huynh, T. and Landsman, V., 2018. Prevalence of low back pain, pelvic girdle pain, and combination pain in a pregnant Ontario population. Journal of Obstetrics and Gynaecology Canada, 40(8), pp.1038-1043.

Wu, A., Dong, W., Liu, S., Cheung, J.P.Y., Kwan, K.Y.H., Zeng, X., Zhang, K., Sun, Z., Wang, X., Cheung, K.M.C. and Zhou, M., 2019. The prevalence and years lived with disability caused by low back pain in China, 1990 to 2016: findings from the global burden of disease study 2016. Pain, 160(1), p.237.

Xu, M., Chen, X. and Kou, G., 2019. A systematic review of blockchain. Financial Innovation, 5(1), pp.1-14

Xue, X., Yang, X., Deng, Z., Chen, Y., Mao, X., Tu, H., Zhou, L., Li, N., Sun, J., He, Y. and Zhang, S., 2022. Effect of Kinesio taping on Pregnancy-related low back pain: A protocol for systematic review and meta-analysis. Plos one, 17(1), p.e0261766.

Yuan, S., Wang, H. and Zhou, J., 2022. Prevalence and risk factors of low back and pelvic pain in women with rectus abdominis diastasis: a multicenter retrospective cohort study. The Korean Journal of Pain, 35(1), pp.86-96.

ZAVUGA, R., Waako, S., Twimukye, M., Mugambe, R.K., Isunju, J.B., Muwonge, H., Masete, I., Kusasira, S. and Guwatudde, D., 2021. Low Back Pain Effects, Management and Coping Strategies among Pregnant Women Attending Antenatal Clinic in Eastern Uganda: A Cross-Sectional Study.

Number of references - 8