Use of Integrative and Complementary Health Practices by professionals in pregnant women with low back pain: integrative review

ABSTRACT

BACKGROUND AND OBJECTIVES:

Integrative and Complementary Health Practices are proposed as possibilities of intervention for women in minimizing the effects of pregnancy and changes associated with this period, especially low back pain. There is a need for health professionals to increase their technical-scientific knowledge in the control of low back pain in pregnant women, as well as to start viewing them as a model of care to be practiced. This study’s objective was to analyze the use of integrative and complementary practices by health professionals in pregnant women with low back pain in the national and international literature.

CONTENTS:

Integrative review in which the search for articles was carried in the following databases: LILACS, BDENF, Scielo, Pubmed, Scopus and Web of Science. The descriptors Pregnant Women, Obstetrics, Low Back, Back Pain and Complementary Therapies were used in Portuguese, English and Spanish. Articles included should have been published from 2006 to 2019 and in the three languages mentioned. After reading the articles, twelve studies were included. With the analysis, two categories were listed: 1) Integrative and Complementary Health Practices used by professionals in pregnant women with back pain and 2) Professionals who use Integrative and Complementary Health Practices in pregnant women with back pain.

CONCLUSION:

The use of Integrative and Complementary Health Practices by professionals can provide new opportunities, greater knowledge, better assistance to pregnant women, their satisfaction and well-being during pregnancy. Such benefits may represent an advance in health promotion, with the potential to improve care.

Keywords:
Back pain; Complementary therapies; Obstetrics; Pregnant women

RESUMO

JUSTIFICATIVA E OBJETIVOS:

As Práticas Integrativas e Complementares em Saúde foram propostas como possibilidades de intervenção para as mulheres na minimização dos efeitos da gestação e das modificações associadas a este período, principalmente a dor lombar.Justifica-se pela necessidade de os profissionais da saúde adensar seu conhecimento técnico-científico acerca dessas práticas no controle da dor lombar em gestantes, bem como passarem a ver as mesmas como modelo de cuidado a ser praticado. O objetivo deste estudo foi analisar na literatura nacional e internacional o uso das práticas integrativas e complementares em saúde pelos profissionais em gestantes com dores lombares.

CONTEÚDO:

Trata-se de uma revisão integrativa em que a busca de artigos foi realizada nas bases/bancos de dados: LILACS, BDENF, Scielo, Pubmed, Scopus e Web of Science. Utilizou-se os descritores Gestantes, Obstetrícia, Dor Lombar, Dor nas Costas e Terapias Complementares nos idiomas português, inglês e espanhol. Os critérios de seleção foram no período de 2006 a 2019 e nos três idiomas citados. Após a leitura dos artigos, foram incluídos 12 estudos e, com a análise, elencados em duas categorias: 1) Práticas Integrativas e Complementares em Saúde utilizadas pelos profissionais em gestantes com dores lombarese 2) Profissionais que utilizam as Práticas Integrativas e Complementares em Saúde em gestantes com dores lombares.

CONCLUSÃO:

A utilização das Práticas Integrativas e Complementares em Saúde pelos profissionais pode proporcionar novas oportunidades, maior conhecimento, melhor assistência às gestantes, satisfação e bem-estar durante a gestação. Tais benefícios podem representar um avanço na promoção em saúde, com potencial de melhoria da assistência.

Descritores:
Dor lombar; Dor nas costas; Gestantes; Obstetrícia

INTRODUCTION

Integrative and Complementary Health Practices (ICHP) have been proposed as possibilities of intervention for women in order to alleviate the effects of pregnancy, especially the modifications/alterations associated with this period, including low back pain¹.

They have been used by health professionals for different purposes and can be applied in various clinical conditions, be a complement to biomedical treatment, depending on the condition of the person and, therefore, provide a specialized care with effective results. It’s important to emphasize that professionals need to know the contraindications of ICHP for each stage of pregnancy, in order not to cause lesions in the mother-fetus binomial².

Pregnancy is a period of great physical, psychic and social changes in the woman’s body and mind, which occur in the organism and are temporary, but present in almost the entire gestational period. Therefore, it’s necessary to be aware of these changes that women experience, because many times they do not require pharmacological treatment, but rather orientations, monitoring and integrative techniques or practices that direct this period in a pleasant and healthy path.

Thus, health professionals have an essential role in the application of these practices that are recognized and supported by the current legislation. It’s necessary to understand the benefits that each practice can provide in the day-to-day practice of health professionals and to act with integrative practices as a model of care in the different levels of attention, promoting integral assistance.

Based on the above, this study is justified by the importance and necessity of health professionals to broaden their technical-scientific knowledge about ICHP in the control of low back pain in pregnant women, as well as to visualize it as a model of care to be studied/practiced in their work context. The hope is to fill the gaps that still exist in the scientific field on this subject and that this knowledge is added to the care practices of these professionals.

This study’s objective was to analyze the use of integrative and complementary health practices by professionals in pregnant women with back pain in the national and international literature.

CONTENTS

Integrative review, for which a specific methodological reference⁴ was adopted. This reference framework addresses six phases that should followed: elaboration of a guiding question, literature search or sampling, data collection, analysis of included studies, discussion of results and presentation of the integrative review⁴.

The PICo strategy was used to prepare the guiding question, where P (population/problem): professionals; I (intervention): ICHP; (context): pregnant women with back pain. The guiding question of the research was: how are ICHP used by professionals in pregnant women with back pain? The search for scientific articles was carried out, in a paired and independent way, by two researchers in the following databases: LILACS, BDENF (Nursing Database), Scielo, Pubmed, Scopus and Web of Science.

In order to find the articles that composed the sample, the following DECs were used: Pregnant Women, Obstetrics, Low Back Pain, Back Pain and Complementary Therapies, in Portuguese, Spanish, and English; and the descriptors of the MESH Database: Pregnant Women, Obstetrics, Low Back Pain, Back Pain and Complementary Therapies. The Boolean operator represented by the term ‘’AND’’, as well as paired associations, were used. The search strategies for the articles in each database are represented in table 1.

Table 1
Database search strategies

Databases	Keywords associations
LILACS   BDENF   Scielo	Gestantes AND Dor Lombar Gestantes AND Dor nas Costas Gestantes AND Terapias Complementares Obstetrícia AND Dor Lombar Obstetrícia AND Dor nas Costas Obstetrícia AND Terapias Complementares Dor Lombar AND Terapias Complementares Dor nas Costas AND Terapias Complementares   Mujeres Embarazadas AND Dolor de la Región     Lumbar Mujeres Embarazadas AND Dolor de Espalda Mujeres Embarazadas AND Terapias     Complementarias Obstetricia AND Dolor de la Región Lumbar Obstetricia AND Dolor de Espalda Obstetricia AND Terapias Complementarias Dolor de la Región Lumbar AND Terapias     Complementarias Dolor de Espalda AND Terapias Complementarias   Pregnant Women AND Low Back Pain Pregnant Women AND Back Pain Pregnant Women AND Complementary Therapies Obstetrics AND Low Back Pain Obstetrics AND Back Pain Obstetrics AND Complementary Therapies Low Back Pain AND Complementary Therapies Back Pain AND Complementary Therapies
Pubmed   SCOPUS   Web of Science	Pregnant Women AND Low Back Pain Pregnant Women AND Back Pain Pregnant Women AND Complementary Therapies Obstetrics AND Low Back Pain Obstetrics AND Back Pain Obstetrics AND Complementary Therapies Low Back Pain AND Complementary Therapies Back Pain AND Complementary Therapies

Publishing period from 2006 to 2019 was defined one of the inclusion criteria. Articles with abstracts and full texts in Portuguese, Spanish and English were selected from the databases. Publications that were duplicated in the databases were excluded.

An instrument was used to collect data from the integrative review that contains variables such as: study data identification (title, journal, authors, year, country of publication and language) and study characterization (objectives, type of study, subjects, results and conclusions)⁵. Finally, for the analysis of the studies included in the research, the Levels of Evidence proposed by Polit and Beck were adopted⁶.

During the databases search, 10.791 articles were located, being 9 eligible articles in LILACS, 14 in Scielo, 6 in BDENF, 25 in Pubmed, 25 in Scopus and 23 in Web of Science, totaling 102 eligible articles. There were 4 duplicates in LILACS, 11 in Scielo, 6 in BDENF, 19 in Pubmed, 21 in Scopus and 21 in Web of Science, totaling 82. Subsequently, 8 more articles were excluded for duplicity. Therefore, 12 articles were selected for critical and analytical reading, 3 in LILACS, 3 in Scielo and 6 in Pubmed (Figure 1).

Figure 1
Distribution of the articles found and selected according to databases in the 2006 to 2019 period

Source: Prepared by the authors.

The summary of the results achieved is presented in table 2, regarding the variables: authors, title, journal, year, country of publication, language and field.

Table 2
Characteristics of the studies included in the integrative review according to databases in the 2006 to 2019 period

Authors	Journal	Year	Country of publication	Language	Field
Ferreira, Pitangui and Nakano7	Fisioterapia Brasil	2006	Brazil	Portuguese	Physiotherapy
Pitangui and Ferreira8	Fisioterapia em movimento	2008	Brazil	Portuguese	Physiotherapy
Ekdahl and Petersson9	Scandinavian Journal of Caring Sciences	2010	Sweden	English	Nursing
Sadr, Pourkiani-Allah-Abad and Stuber10	Chiropractic & Manual Therapies	2012	Canada	English	Physiotherapy
Akmese and Oran11	Journal of Midwifery & Women's Health	2014	United States	English	Nursing
Hall et al.12	Medicine	2016	Australia	English	Medicine
Silva et al.13	Revista Gaúcha de Enfermagem	2016	Brazil	Portuguese	Nursing
Martins et al.	Revista da Rede de Enfermagem do Nordeste	2017	Brazil	Portuguese	Nursing
Hughes et al.15	Complementary Therapies in Clinical Practice	2018	United States	English	Nursing
Martins et al.16	Revista da Escola de Enfermagem da Universidade de São Paulo	2018	Brazil	Portuguese	Nursing
Holden et al.17	Global Advances in Health and Medicine	2019	United States	English	Medicine
Martins et al.18	Acta Paulista de Enfermagem	2019	Brazil	Portuguese	Nursing

Source: Prepared by the authors.

From the selected articles, 10 were published in the last 10 years, 7 in the last five years and 2 in 2006 and 2008. Six articles were published in journals located in the United States and the other six in journals located in Brazil, being the same proportion in Portuguese and English (Table 2). As for professional field, 7 authors were nurses, 3 physiotherapists and 2 doctors.

Regarding the type of study, there was a predominance of review studies, being one an integrative review, two narratives and one systematic review with meta-analysis, two quasi-experimental studies, three randomized and controlled clinical studies, two qualitative studies and only one descriptive and quantitative research. Regarding the participants evaluated in the selected studies, the predominant study population, varying according to gestational age, was the pregnant women who complained of low back pain. By analyzing the studies’ level of evidence in this review, using the reference mentioned above⁶, one study obtained evidence level I classification, five studies level II, three level VI and three articles included and evaluated had no evidence level.

Through the analysis of the results and conclusions of the selected articles, two categories were listed: 1. ICHP used by professionals in pregnant women with back pain; and 2. Professionals who use ICHP in pregnant women with back pain.

ICHP used by professionals in pregnant women with back pain

The most cited ICHP among the 12 articles included in this review was acupuncture^7,9,14-18. In the context of pregnancy, this practice has been widely used for low back pain relief, since the stimulation of points throughout the body generates release by the central nervous system of neurotransmitters and other substances responsible for the effect of analgesia, restoration of organic functions and maintenance of immunity. It can also provide energetic balance and physical, mental, spiritual and emotional health¹⁸.

Literature generally reveals that pregnant women report well-being after the first sessions and report pain reduction, including low back, gradually as the number of sessions of this practice progresses. Thus, the greater the number of sessions they have undergone, the better the results and the greater the decrease in pain intensity. Besides satisfaction and well-being, there is improvement in mobility, sleep and tiredness, providing better quality of life for pregnant women¹⁸.

ICHP, mainly acupuncture, can be used alone or in combination with other therapies. Most of them are safe, simple, with few contraindications and minimal adverse reactions. Therefore, professionals should be aware of the few contraindications of these ICHP, being careful with the weeks/months of gestation in order to avoid risks to the mother-fetus binomial¹⁸.

Another ICHP mentioned and used by professionals is relaxation^7,8,11. A systematic review study concluded that there are several positive effects of relaxation techniques during pregnancy, including maternal, fetal and neonatal results¹⁹.

Some of the positive effects of this technique are: fewer hospital admissions, obstetric complications, premature births, cesarean sections, postpartum complications, reduced fetal heart rate, higher birth weight and better neonatal performance/development. Cited effects on mothers: reduction of maternal stress, muscle contractions and sensation of pain, as well as improvement in quality of life¹⁹.

Another mentioned ICHP is massotherapy^7,12. Additionally, a systematic review study and meta-analysis found a positive effect in reducing pain intensity, including low back pain, in the massage performed by the partner in the pregnant women when compared to relaxation. There is a general positive effect in these women when osteopathy, massage and relaxation therapies used in this study were combined¹².

According to the analyzed articles, another ICHP mentioned and applied by professionals was chiropractic^10,15. A qualitative study investigated the experience of chiropractic treatment in pregnant patients with back pain, as well as that of their chiropractors. There were positive results in the perception of both. It should be noted that the patients involved reported they were generally satisfied with the chiropractic care they received during pregnancy and also had positive results that favored the reduction of low back pain, improvement in range of movement and well-being of the body’s overall function¹⁰.

Other ICHP mentioned in the review were aromatherapy, phytotherapy, homeopathy and reflexology, analyzed in a single study¹⁵. In an integrative review it was evident that there are no studies addressing specific data on aromatherapy applied to pregnant women with low back pain complaints. However, they concluded that the use during pregnancy should be recommended due to its antinociceptive action that reduces low back pain and promotes anxiolytic action specially at the end of pregnancy²⁰.

As for phytotherapy, an integrative review study concluded that the stereotyped view in which it’s associated only with low-income, poorly educated women living in rural areas does not reflect the global reality. Regardless of the geographical location, socioeconomic and ethnic-cultural conditions that may distinguish them, most women around the world use herbal medicine during pregnancy, some use ginger as an antiemetic, others use chamomile and mint as a form of relaxation, for headache relief, myalgia and back pain²¹.

As for homeopathy, a review study concluded good adherence of pregnant and breastfeeding women in homeopathic treatment for the most varied common symptoms in the pre and postpartum period, labor, breastfeeding, postpartum emotional stability and newborns worries such as colic and gas. However, qualified health professionals are necessary for prescription and treatment, guiding and monitoring possible adverse effects, always aiming at its success²².

Another ICHP referred to was reflexology, also called reflexotherapy or zone therapy. An experience report qualitative study developed with nine pregnant women from different gestational periods of a Estratégia de Saúde da Família (ESF - Family Health Strategy) which received reflexology showed immediate results, such as the sensation of well-being, favoring of sleep, reduction of pain, including low back pain, which together contributed to the sensation of relaxation. This technique performed in pregnant women provided positive results and most participants felt well-being during and even after the practice²³.

Another practice found in this review, one more of the therapeutic resources that promote back pain relief during pregnancy, was hydrotherapy⁷. The execution of movements with the body submerged in water reduces joint stress, the impact of joints and the risk of injuries in pregnant women. It also minimizes musculoskeletal discomfort caused by pregnancy, in addition to promoting a strong postural control that provides low back analgesia²⁴.

Acupressure was also used in pregnant women¹³. In a qualitative and descriptive study developed with 15 pregnant women from a Unidade Básica de Saúde (UBS - Basic Health Unit) in Natal-RN, who received acupressure during pregnancy, it was found that at each touch and application of the technique, facial and body expression emitted information of well-being, relief of discomfort and tensions in muscle bundles, especially in the low back, shoulder and cervical regions. The authors concluded that there was a discomfort reduction in pregnancy, such as cramps, lower limb fatigue, back pain and headache¹³.

Osteopathy was also mentioned¹². The treatment of somatic dysfunction can improve homeostasis, provide comfort and improve quality of life as the maternal body adapts to the physiological and structural changes of pregnancy. Through the application of osteopathy there can be significant improvement in women’s lives during pregnancy²⁵.

Finally, yoga was also used by professionals¹⁷. A randomized clinical trial conducted with 168 women who presented low back pain and performed yoga concluded that this prenatal intervention improves pain and provides well-being, reducing the overall burden of pregnancy symptoms and improving postural stability of pregnant women¹⁷.

Professionals who use ICHP in pregnant women with back pain

Of the 12 articles included in this review the most cited professional was the nurse^{9,11,13-16,18}. ICHP are reaffirmed as a specialty of Nursing by the 581 Resolution of 2018 of the Conselho Federal de Enfermagem (COFEN - Federal Council of Nursing), which ensured for these professionals actions and research development in the general field of ICHP²⁶.

A semi-experimental study concluded that the practice of acupuncture performed by nurses in the habitual risk prenatal provided positive effects favorable to the health of pregnant women, reducing pregnancy discomforts and, especially, lower back pain from the second session forward and, thus, gradually the number of sessions advanced¹⁸.

The physiotherapist was another professional cited in this review^7,8,10. Resolution 380 of 03/11/2010 of the Conselho Federal de Fisioterapia e Terapia Ocupacional (COFFITO - Federal Council of Physiotherapy and Occupational Therapy) regulated the use of some ICHP by the physiotherapist such as phytotherapy, manual, meditative and body practices, Bach flower remedies, magnetotherapy, anthroposophic physiotherapy, thermalism/crenotherapy/balneotherapy and hypnosis. By this Resolution, they can exercise and prescribe ICHP, as long as they prove before the Council the recognized certification of knowledge of practices²⁷.

A narrative review study found that pregnancy is a factor that limits the pharmacological treatment of back pain and other discomforts. Thus, it’s crucial that the physiotherapist acts based on the knowledge they hold on the most appropriate and effective resources in this period⁷.

Another professional also cited in this study was the physician^12,17. By means of the Resolutions 1000, of 06/04/1980 and 1455, of 08/11/1995, of the Conselho Federal de Medicina (CFM - Federal Council of Medicine), homeopathy and acupuncture were recognized, respectively, as medical specialties that provided physicians with the legal backing to practice the described ICHP^28,29.

In that context, a randomized controlled pilot study developed by physicians performed a yoga intervention in prenatal patients with 12 to 26 weeks of pregnancy in an academic medical center in the United States. These professionals found that performing prenatal yoga improved gestational low back pain and promoted maternal well-being, being a viable and safe technique¹⁷.

Although these health professionals are already supported by Resolutions of their Councils, it should be mentioned that, in general, all of them can face facilitations and difficulties when performing ICHP. One of the facilities for the applicability of ICHP is the fact that they are a social alternative, of paramount importance, which increases access to health care for the population, qualifies and values their work due to its focus on integral care³⁰.

The ICHP are presented in a way that is economically viable and fast to implement, so as to ensure access to health and humanize care, contributing to a healthier life and reducing unnecessary interventions. They have been gaining space and notoriety with health professionals and pregnant women for the benefits provided to them and to newborns³⁰.

On the other hand, there are some challenges faced by health professionals that make the applicability of ICHP difficult. A documentary study found that the number of professionals who work with ICHP or have the knowledge to prescribe and refer users to this type of care is reduced. There are also professionals who have specialization or courses in these therapies, but they are not offered in the Basic Health Units where they operate, nor do they have the time, space or authorization to practice them³¹.

Some of the obstacles may be due to gaps in the professional training process, as issues related to ICHP are not always addressed during graduation. It’s also noticeable that there are few professionals working in research and extension activities in universities and clinical practice in Basic Health Units and private institutions. More professionals in this field would contribute to the increase of knowledge with scientific basis and dissemination of these therapies to the community³¹.

In view of the above, it’s important to emphasize that, taking into account the facilitations and difficulties involved in the implementation of ICHP, health professionals can reconsider the quality of care for the obstetric public, not only through pharmacological treatment, but with an emphasis on the applicability of ICHP to the entire pregnancy cycle, contributing in an essential and significant way to an integral and humanized care, configuring an advance for the health of pregnant women¹⁶.

It’s important to note that the present study had some limitations, such as the diversity of key words and concepts that are related to ICHP, which may have made it difficult to locate scientific productions in the researched databases. Another limitation refers to the difficulty of collecting information from the included articles regarding the type of study, levels of evidence and limitations, in addition to the small number of articles on this topic.

The standardization of keywords related to ICHP is necessary, as well as the inclusion of new controlled descriptors that address this area in order to facilitate and encompass the collection of data. It’s essential to conduct new scientific studies with a higher level of evidence and methodological rigor that use reliable measures in order to evaluate the effects of ICHP on the health of pregnant women with back pain.

CONCLUSION

Given the positive results on the use of ICHP in pregnant women with back pain, the inclusion of these therapies as an adjunct strategy in the promotion and prevention of women’s health throughout the pregnant cycle is necessary for a better quality of life in this period. In addition to the benefits provided by reducing low back pain, these therapies can also reduce other symptoms and discomfort caused by pregnancy.

With the use and applicability of ICHP by professionals, new opportunities, greater knowledge and autonomy will be offered to these workers, as well as better assistance, satisfaction and well-being to pregnant women. In this way, more progress in health promotion, better assistance in hospital care and in the basic health network will be achieved.

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Publication Dates

• Publication in this collection
  10 Mar 2021
• Date of issue
  Apr-Jun 2021

History

• Received
  27 Aug 2020
• Accepted
  21 Jan 2021