1 Ann Quinlan-Colwell PhD, RNBC, DAAPM

Ann Quinlan‐Colwell
PhD, RNBC, DAAPM
 Author Conflict of Interest;
 A. Quinlan‐Colwell,
A consultant and presenter of non‐branded education for Mallinckrodt
 1) Describe the challenges and barriers to providing good management of chronic pain during pregnancy
 2) Explain the importance of using multi‐modal analgesia (MMA) when treating chronic pain during pregnancy
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 Myths ‐ Misinformation – Misconceptions ‐ Beliefs
 Communication
 Underreporting
 Culture differences
 Pain Behaviors
 Coping styles
 Fear
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AQC_January_2012
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 Effective
 Stoic
 Whining
 Complaining
 Over reliance on medications
 Substance misuse ‐ abuse
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 Reluctant to seek treatment for pain
 Unable to afford medications or procedure to manage pain
 Insurance determines treatment
 Depletion of reserve money
 Lack of money for complementary therapies
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 Educational Limitations
 Legal concerns
 Concerns regarding fetal well being
 Competing priorities
 Concern regarding “drug seeking”
 Complicated comorbidities
 Time
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 Epidemiology
 Prevalence  ~ 25 – 56% lumbopelvic or peripartum pelvic pain
 ~ 8% become severely incapacitated
 Challenges
 Terminology and definitions
 Formal mechanism for tracking
 Studies
 NY hospital 200 women w/ 56% w/ LBP by Fast, et al, 1987
 Yale study 950 surveys w/68.5% w/LBP by Wang et al, 2004
(IASP, 2007; Wang, et al, 2004)
 Back
 Low back
 Pelvic girdle pain
 Neck
 Pelvis
 Pubic area
 Hip
 Knee  Thorax
(Licciardone, et al, 2010; Vleeming, et al, 2013)
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 Headache
 Nerve entrapment
 Meralgia paresthetica
 Degenerating fibroid
 Carpal tunnel syndrome
 DeQuervain’s tenosynovitis
 Post herpetic neuralgia
(ACOG, 2013; IASP, 2007; Licciardone, et al, 2010)
Pain Control
Maternal Concerns
Safety
Neonate Concerns
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 Physiological Impact of poorly controlled pain
 Immobility
 Premature delivery
 Psychological Impact of poorly controlled pain
 Antenatal and postnatal depression
 Stress cascade resulting from unrelieved pain
 Withdrawal from opioids
 “the fetus is a passive recipient of any medication that may be administered” (IASP, 2007)
 Rx that are harmful to developing fetus
 Neonatal Abstinence Syndrome
 Intrauterine withdrawal
 Neural Tube Defects (Yazdy, et al, 2013)
 All opioids are Pregnancy Class C
 Prevalence
 2001 Wilbourne et al reported opioid use in 7.5% of
pregnancies
 2011 Kellogg et al reported steady increase from 1998‐2009
 Indications for using opioids during pregnancy





Chronic pain Genitourinary pain w/ pathologic evidence
Headaches
Orthopedic w/ pathologic evidence
Other (CA; varicosities; neurofibromatosis)
(APS, 2009; Kellogg et al, 2011)
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 Increased risk of miscarriage
 1st and 2nd trimesters (up to 30 weeks) probably ok
 3rd trimester – NSAIDS are contraindicated
 NSAIDS inhibit cyclo‐oxygenase
 Cyclo‐oxygenase dilates the ductus arteriosus & pulmonary resistance vessels
 Inhibition could cause premature closure
(Kennedy, 2011)
 Platelet inhibition
 Possible maternal and fetal bleeding
 Associate with increase risk of miscarriage
 Associated with increased risk of vascular disruption;
gastroschisis
 BUT, may be Rx’d to reduce other adverse outcomes
(Babb, 2010; Kennedy, 2011)
 “Women receiving opioid‐assisted therapy who are undergoing labor should receive pain relief as if they were not taking opioids because the maintenance dosage does not provide adequate analgesia.” (ACOG, 2012)
 Generally require increase opioid dosing
 Avoid opioid agonist‐antagonists

 Do not use buprenorphine in a pt taking methadone
(ACOG, 2012)
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 Epidural or spinal anesthesia
 Local anesthetic
 Injectable NSAID or acetaminophen
 Breathing and Relaxation Techniques
 40 Post Caesarean Section patients  Group 1 – IT bupivacaine + morphine + incisional bup
and ibuprophen + acetaminophen to d/c
and prn codeine
 Group 2 ‐ IT bupivacaine + IV morphine PCA weaned to
acetaminophen + codeine
 Pain at Rest
0.6 vs. 2.1 (p < 0.0001)
 Pain with Activity
1.9 vs. 4.1
(p < 0.0001)
(Rosaeg, et al, 1997)
 533 breast feeding mothers
 CNS depression rate in neonates
 Oxycodone  Codeine
 Acetaminophen 20.1% (28/139)
16.7% (35/210)
0.5% (1/184)
 Group characteristics
 Mothers taking codeine more likely first time mothers
 Infants exposed to oxycodone were younger
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 May be safe in small doses (< 30 mg/ day)
 Hydrocodone metabolizes to hydromorphone
 Sauberan, et al:
 Little to no hydromorphone excreted into breast milk
 Concern is  Only one study
 Neonate metabolism  Awareness, Education, Assessment still needed
(Sauberan, 2011)
 CYP2D6 gene
 Codeine – metabolizes to morphine metabolite
 Oxycodone – metabolizes to oxymorphone (14 x potent)
 Know:
 Potential
 Underlying mechanisms
 r/o in lethargic infants
 Educate breast feeding mothers taking opioids
 be alert for signs of lethargy and sedation
 seek prompt medical assistance
(Kennedy, 2011; Koren et al, 2006; Timm, 2013; vandenAnker, 2012)
 Non‐pharmacologic interventions
 Acetaminophen
 NSAIDs during pregnancy
 do not seem to increase risk of adverse birth outcome
 But should be avoided after 30 weeks
 and are associated with increased risk of miscarriage
 Opioids in pregnancy  do not cause fetal malformations
 but can result in neonatal abstinence syndrome
(Kennedy, 2011)
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 Identify and address the cause of pain
 Individualized plan of care
 Patient education: ‐ indications for different interventions
‐ potential side effects
 Start at low dose and gradually titrate dose
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Is the Key to Pain Management
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 Determine Etiology
 Obstetric
 Ectopic pregnancy
 Preterm labor
 Placental abruption
 Uterine rupture
 Gynecologic
 Adnexal torsion
 GI
 Appendicitis
 Intestinal obstruction
 Hepatobiliar
 Acute fatty liver of pregnancy
 GU
 Hydronephrosis of pregnancy
 Renal calculi
 Vascular
 Gonadal vein thrombosis or syndrome
 Messenteric vein thrombosis
 Aneurysm rupture
 Intervene accordingly (Woodfield, et al, 2010)
 Avoid ergots and sodium valproate  Non‐pharm
 Hydration
 Diet
 Acetaminophen
 Propranolol generally considered safe
 Combo metoclopramide & diphenhydramine (MAD)
 metoclopramide ‐ used to tx heartburn 2/2 reflux
 Diphenhydramine ‐ antihistamine OTC allergy/sleep aids
 considered safe in pregnancy & reasonably priced
(ACOG, 2013; Mehta, 2011)
What is 32%
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 LBP is the ____________ cause for HCP visits in US.
 At least __ % of people will have LBP at some time.
 Most women first experienced LBP _____ _____.
 In pregnancy LBP interferes w/ ability to _____ and ______
_____ _______ ______.
 Women who have had LBP during pregnancy are at greater risk of experiencing LBP _____ ______.
 _______% of women who avoid subsequent pregnancies 2/2 fear of recurrence of LBP.
George, et al, 2013; Wang, et al, 2004
 LBP is the ____________ cause for HCP visits in US.
 At least __ % of people will have LBP at some time.
 Most women first experienced LBP __________ _____.
 In pregnancy LBP interferes w/ ability to ______ and _____________.
 Women who have had LBP during pregnancy are at greater risk of experiencing LBP ______________.
 ____% of women who avoid subsequent pregnancies 2/2 fear of
recurrence of LBP.
George, et al, 2013; Wang, et al, 2004
 Age
 h/o LBP
 h/o LBP during menstruation
 h/o LBP during prior pregnancies
(Wang, et al, 2004)
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 Use of birth control pills
 Hormonal therapy 2/2 infertility
 Caffeine
 Cigarette smoking
 Physical exercise
 Previous epidural or spinal procedures
 Repetitive daily activities
 Body weight pre‐pregnancy (others disagree)
 Number of pregnancies
(Wang, et al, 2004)







Stretching Exercise
Frequent rest
Cold or hot compresses
Supportive belt
Acetaminophen
Complementary therapies









Acupuncture
Massage
Chiropractic
Osteopathy
Aromatherapy
Relaxation
Herbs
Yoga
Energy work (Reiki, Therapeutic Touch)
(Wang, et al, 2002, 2004)  Patient Education from 1st trimester
 Posture
 Body mechanics
 Mechanical supporter information
 Physical Therapy
(Wang, et al, 2004)
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 STOB = Standard of Obstetric Care
 MOM = Multimodal musculoskeletal & obstetric management with weekly chiropractic specialist based on biopsychosocial model
 Education
 Reassurance
 Manual therapy
 Stabilization exercises
(George, et al, 2013)
 STOB group at 33 weeks
 Significant increase in pain in 5 indices
 MOM group at 33 weeks






Statistically significantly less pain in 7 indices
Significantly less sleep difficulty
Improved ROM
Stability
Less lumbar and pelvic joint irritation
NO ADE
 Conclusion
MMA is beneficial
George, et al, 2013
 Prevention
 Shoes with good arch support
 Firm mattress
 Good body mechanics
 Chairs w/ good back support
 Small pillow to support lower back
 Lumbar supports
 Side sleeping w/ pillow/s between legs or under abdomen
 Treatment
 Regular exercises to strengthen & stretch muscles
 Good posture
 Heat and/or cold
14
 OMT – a form of manual therapy by DO
 Licciardone, et al study
 144 subjects
 3 groups
 UOBC
increase in NRS
 UOBC + SUT
no change in NRS
 UOBC + OMT decrease in NRS
most disability rise
mod disability rise
minimal disability rise
 Goal: achieve functional physical restoration
 Role: prescribe, facilitate, pace therapeutic interventions  PT influence pain by:
 Resolving inflammation
 Assisting with tissue repair
 Stimulating temporary pain relief
 Moving nerve conduction’
 Providing counterirritant
 Modifying muscle tone
 Reducing chance of maladaptive neuropathic changes
(Allen, et al, 2006)
 Systematic Review 1992‐2013
 22 RCT studies
 Dx – lumbopelvic pain
 Interventions
 Combination (education, relaxation)
“helpful”
 Exercise therapy
moderate evidence
 Manual therapy
limited evidence
 Material support
limited evidence
 Conclusion
 Evidence based recommendation for use of exercise therapy during pregnancy to treat lumbopelvic pain
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 Ee, et al Systematic Review (2008)
 Limited evidence supports Ac
for pregnancy related pelvic/back pain
 Additional study needed
 Elden et al study (2008)
 351 women w/ pelvic girdle pain
 3 groups
 standard of care
22% good or very good help
 SOC + stabilising exercises
81% good or very good help
 SOC + acupuncture
83% good or very good help
 minor ADE reports  but no severe ADE effect on pregnancy, deliver, fetus
 Wang et al Study (2010)
 152 Pregnant women w/ posterior pelvic/LBP  Control, sham acupuncture, acupuncture
 Decrease in pain
 Control group
 Sham acupuncture group
 Acupuncture group
18%
32%
68%
 Significance between groups
 Significant improvement in functional status  ADEs
 No adverse pregnancy outcomes
 One in each group bed rest post study
 Ear tenderness 1/54 Ac group and 3/50 Sham Ac group
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 Environmental Modification
 Education
 Cognitive Behavioral Interventions
 Healing Arts
 Physical  Energy Based Interventions
 Exercise
 Spirituality & Prayer
 Devices
 Other Complementary Interventions
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 Lighting
 Sounds
 Temperature
 Odors
 Position
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 Patient Position
 Head
 Neck
 Limbs
Pillows
Side rails
17
 Include family and caregivers
 Focus on:
 Etiology
 Interventions to alleviate pain
 Pharmacological preparations
 Side effect management
 Comfort measures
 Nonpharmacological interventions
 Muscle relaxation
 Dietary needs and measures
 Rest and relaxation
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 Usual bio‐rhythms
 Patient priorities
 Pre‐medicate
 Pace activities
 Educate re: benefits
 Schedule
 activities
 rest
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Cognitive Behavioral Therapies
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 Rationale for using CBT
“altering patterns of negative thoughts and dysfunctional
attitudes leads to more positive thoughts, emotions, and behavior changes, including improved self‐
management.”
 Underlying assumption is that:
perceptions and evaluations influence emotional and behavioral reactions to painful conditions
(Menzies, Taylor & Bourguignon, 2006, p.24)
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 Involves increased mental focus and concentration with expanded awareness, diminishing perception and interest in peripheral sensations, thoughts, and feelings of the external environment.
 Used since early 1800’s
 Generally safe and effective
 Caution with people with h/o mental illness
 Effective for:





Osteoarthritis
Fibromyalgia
Cancer
Headaches
Sickle cell disease
( Anselmo, 2009; Fass, 2008).
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 With significant attention required for activity,
pain scores decreased
(Berman, Iris, Bode, & Drengenberg, 2009; Ersek, Turner, & Kemp, 2006; Veldhuijzen, Kenemans, De Bruin, Olivier, & Volkerts, 2006).
 Specific Techniques  Imagery
 Focal point attention
 Music
 Counting
 Pleasurable leisure activities
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 Imagery is “a dynamic, psychophysiologic process in which a person imagines, and experiences, an
internal reality in the absence of external stimuli.”
(Menzies, Taylor & Bourguignon, 2006, p.24)
 Imagery is “the spontaneous flow of thoughts originating from the unconscious mind” (Seaward, 2004, p. 381)
 Free flow of thoughts  May include:
 Day dreaming
 Reminiscing/14
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 A deliberate process of imagining
 “A conscious choice with intentional instructions”
(Seaward, 2004, p. 381)
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 A coach/guide is added to deliberate process of visualization
 Generally begins with relaxation
 Research
 Studies small
 Generally effective when used 2 – 3 times daily  Cautions:
 Always have the person choose the location
 Select a comfortable and SAFE location
 Not indicated with  psychotic disorders
 Cognitive impairment
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 “Person may experience an affective, behavioral or physiologic response without a real stimulus event.”
(Menzies, Taylor & Bourguignon, 2006, p.24)
 Improved: function, self‐efficacy and reduced pain;
reduced emotional distress
 Beneficial with:
 Fibromyalgia (improvement in tender point measures)
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Behavioral Interventions
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 Combine psychological and physical responses

 Involve parasympathetic system, visceral and somatic organs
 Cerebral, physical and
tensions are released
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 Diaphragmatic
 Square
 Conscious
 Lamaze
 Yoga
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 Also called “soft belly breathing”
 Process:
 Slowly inhale
 Focus bringing inhaled air down into abdomen
 Watching abdomen fill with air
 Exhale
 Focus on watching air leave abdomen
 Analogous to watching an imaginary balloon
 Benefits:
 Easy to learn
 Helps relaxation process
 No known negative consequences
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 Developed to help people relax muscles that become tense because of anxiety, stress, or pain
 Benefits
 Reduced muscle tension
 Reduced stress
 Alters patterns of muscle activities that cause increased pain
 Alters the emotional response to pain
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 No tensing
 Images
 Color
 Guided PMR
 Mindfulness PMR
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 the use of “music to address physical,
emotional, cognitive, and social needs of individuals of all ages” (AMTA, 2004).
 Used to promote wellness and improve health including managing stress and pain during activities,
at rest, and while preparing for sleep (Herr et al., 2006).
 Suggested that beneficial effects of music therapy are related to arousal of emotional responses and
distract from the pain experience, thus interrupting
pain perception (Kinney & Faunce, 2004).
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 Pet Visitation
 Animal Assisted Therapy
 Pet ownership
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25
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 Superficial heat
 Heating pads, hot water bottles, poultices, hot compresses, heat wraps, infrared heat lamps
 Soothe musculoskeletal pain &/or muscle spasms
 Some evidence of relief of short term relief of low back pain
 Cryotherapy
 Ice, cold cloths, cold gel packs, ice massage
 No research to support effectiveness or guide
treatment
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 Limit time  Limit temperature extremes
 NEVER use heat over transdermal fentanyl patches
 AVOID using heat with capsaicin cream
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26
 “The practice of skilled touch for the purposes of reducing pain brought about by injury disease or prolonged stress”
(Calenda & Weinstein, 2008, p. 144).
 Effective:
 Low back pain
 Dementia (hand massage)
 Generally considered safe
 Cautions:
 Some discomfort  Reactions to oils
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 a contemporary interpretation of ancient healing
practices developed in 1973 by Dolores Krieger, and
Dora Kunz
 It is the conscious and intentional use of hands to direct human energies with the intent of helping or healing someone through modulation of their energy field (Krieger, 1979; Krieger, 2002)
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 a technique using focused pressure on the hands or feet with the intent of stimulating certain reflex areas or zones that correspond to the various body organs.
 It is believed that stimulation can facilitate an
improved flow of energy, promoting healing or achieving homeostasis.
 Rare and mild adverse effects include fatigue, headache, nausea,
perspiration, and diarrhea.
(Bisson, 2008)
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 Central to maintaining function
 Reconditioning exercises
 Stretching
 Cardiovascular
 Strengthening
 Individualized programs
 Various locations
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 “ philosophy of living” “unites physical, mental, and
spiritual health” involves breathing & stretching
exercises (Anselmo, 2009)  Not necessary to adopt philosophy of yoga  Postures & breathing exercises designed to quiet &
“cleanse” mind & body (Cashwell, Bentley, & Yarborough, 2007)
 Exercises can be started very gently  Good to recondition muscles and joints  It is reported to be effective in
reducing pain in older adults.
 may be modified to meet particular needs (Morone & Greco, 2007
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 Meditative practice in the Christian tradition
 Focuses on words or sounds  Considered to be nondenominational & appropriate for people of all faiths.  Contemplative journey is the vehicle in a process of letting go (Keating, 1999)
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 Type of meditation from the Buddhist tradition
 Intent is to release negative emotion and embrace a sense of love
 Begins with evolving positive feelings & love toward:
loved ones
then toward self
then toward a person who did harm to person meditating
 Relationship between pain & anger
 Carson et al study
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 Introduced by Jon Kabat‐Zinn as a clinical intervention for chronic pain
 “moment to‐ moment awareness” that “is cultivated by purposefully paying attention to things we ordinarily never give a thought to” (Kabat‐Zinn, 1990, p. 2)
 Can be integrated with daily activities, such as breathing, sitting, walking, washing dishes, or driving
 Incorporated with learning and practicing
mindfulness are patient, nonjudgmental, accepting, and nonstriving attitudes.
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30
 Pain is reduced through surface electrodes, which
emit high or low frequency pulsed electrical currents that selectively stimulate particular sensory or motor nerve fibers through a portable device (Dreeben, 2007; Somers & Clemente, 2006)
 Research shows inconsistent findings
 A study using rats indicated that TENS
is effective for allodynia and complex
regional pain syndrome
(Somers & Clemente, 2006). AQC_11_11
 Use of volatile & essential oils of aromatic plants that have been extracted for therapeutic use when inhaled through the olfactory system  Long considered an established portion of health care in the UK, Japan, and Australia, where the majority of research has been done.  More research is needed in the area of aromatherapy with pain, but early work is promising (Barde, Reichow & Halm, 2009)
 Certification for nurses interested in aromatherapy
(Buckle Associates, 2010)
 Cautions include:
 All essential oils can cause skin irritation & some are toxic.
 Caution with pregnancy
 Topical use of essential oils should be done only
by practitioners trained in their use AQC_11_11
(Cook & Burkhardt, 2004)
 Facilitates person, as active participant,
 to self‐regulate physiological processes  gain control over the body
 Trained biofeedback technicians use concepts of
operant conditioning and specially designed
equipment that mirrors the autonomic physiological
processes to help control those processes to:
 reduce tension and stress
 retrain muscles when muscle tone needs to improve
 train brain waves to improve attention & concentration
(Goldenberg, Burckhardt, & Crofford, 2004; Jensen, Bergstrom, Ljungquist, & Bodin, 2005; McGrady, 2008; Turner, Mancl, & Aaron, 2006)
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10/29/10 AQC
96
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
ACOG (2013). Drug combination for headache during pregnancy shows promise. 501 (C) (6) www/acog.org

ACOG (2014). Easing back pain during pregnancy. FAQ 115

Allen, R. J. (2006). Physical agents used in the management of chronic pain by physical therapists. Physical Medicine Rehabilitation Clinics of North America, 17, 315‐345.

American Pain Society. (2009). Guideline for the use of chronic opioid therapy in chronic noncancer pain – evidence review.

Babb, et al (2010). Treating pain during pregnancy. Canadian Family Physician, 56, 25‐26.

Charlton, J. E. (Ed) (2005). Acute & postoperative pain. Core Curriculum for Professional Education in Pain. 
Ee, C. C., et al (2008). Acupuncture for pelvic & back pain in pregnancy: a systematic review. American Journal of Obstetrics & Gynecology,201 254‐259.

Elden, et al. (2008). Treatments of pelvic girdle pain in pregnant women: adverse effects of standard treatment, acupuncture and stabilising exercises on the pregnancy, mother, delivery and the feus/neonate. BMC Complementary and Alternative Medicine, 8 .

George, et al (2013). A RCT comparing multimodal intervention & standard obstetrics care for low back and pelvic pain. American Journal of Obstetrics & Gynecology, 208, 295e 1‐7.

Kellogg, et al (2011). Current trends in narcotic use in pregnancy and neonatal outcomes. American Journal of Obstetrics & Gynecology, 204, 259e 1‐4.

Kennedy, D. (2011). Analgesics & pain relief in pregnancy & breastfeeding. Australian Prescriber, 34, 8‐10.

Koren, G., et al (2006). Pharmacogenetics of morphine poisoning in a breastfed neonate of a codeine‐prescribed mother. Lancet, 368, 704.

Lam, J. (2012). Central Nervous System depression of neonates breastfed by mothers receiving oxycodone for postpartum analgesia. The Journal of Pediatrics, 160, 33‐37.

Mehta, et al. (2011). Head, face and neck pain science, evaluation & management. Wiley & Sons.

Wang, et al (2002). Complementary & alternative medicine for low‐back pain in pregnancy: a cross‐sectional survey. J of Alternative & Complementary Medicine, 11, 459=464.

Rosaeg, O. P. et al (1997). Peri‐operative multi‐modal pain therapy for caesarean section: analgesia & fitness for discharge. Canadian Journal of Anaesthesia, 44, 803‐809.

Sauberan, J., et al (2011). Breast Milk Hydrocodone and Hydromorphone Levels in Mothers Using Hydrocodone for Postpartum Pain, Obstetrics & Gynecology, 117, 611‐
617.

Timm, N. L. (2013). Maternal use of oxycodone resulting in opioid intoxication in her breastfed neonate. The Journal of Pediatrics, 162, 421‐2.

Van den Anker, J. (2012). Is is safe to use opioids for obstetric pain while breastfeeding. The Journal of Pediatrics, 160, 4‐5.
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