Management of a Case with Postpartum Pelvic Floor Muscle Dysfunction through Different Clinical Reasoning Process

Abstract
Background: in today's world, back pain is commonplace, especially during and after pregnancy. Numerous factors can contribute to these symptoms. Women are more vulnerable to postpartum pelvic floor dysfunctions following vaginal delivery due to changes in bone structure and ligamentous laxity. These dysfunctions can cause excruciating discomfort. The bladder, uterus, and colon are supported by the muscles, ligaments, and tissues that make up the pelvic floor. The pelvic floor is the passageway for the openings in each organ. These organs are supported by the pelvic floor, which functions as a hammock. Nevertheless, a variety of issues may occur if the muscles are weak or if the ligaments and tissues are torn or stretched.

Aim: the paper's aim is to incorporate the clinical reasoning cycle into the management of a case with postpartum pelvic floor muscle dysfunction

Methods: a solitary case study utilizing the clinical reasoning method. The purpose of this study was to explore the management strategies of a postpartum low back pain with pelvic floor dysfunction through clinical reasoning process. It has performed through knowledge, cognition and meta cognition.

Results: at first hypothetico deductive reasoning was used but at last three track reasoning helped me to solve the condition.

Conclusion: this paper presents a case study in managing a case with postpartum pelvic floor muscle dysfunction through different clinical reasoning process. In this study there is a discussion of patient-centered, and evidence-based care provisions through a theoretical examination to manage postpartum pelvic floor muscle dysfunction and it will be helpful for the novice and expert physiotherapy professionals.

Key words: pain status; kegel exercise; family situation

Introduction
In primary care, low back pain is a highly prevalent painful condition. Generally speaking, 60% of patient’s experience recurrences of this pain, which affects 80% of people at least once in their lifetime. In 85% of cases, the disorder's symptoms are unrelated to any specific neurological or etiological causes, and it appears that 23% of patients have chronic conditions and experience pain that lasts longer than 12 weeks¹.

The physical, emotional, and social health of a woman undergoes numerous changes after giving birth. Laxity of muscles and ligaments is brought on by elevated sex hormone levels, preparing a woman's body for childbearing and child growth. Certain physical tasks and movements become challenging and uncomfortable due to this laxity. Pregnancy brings about significant hormonal and social origin changes that last into the postnatal phase².

Pelvic pain may worsen during pregnancy, but lumbar pain is typically stable during this time. Back pain poses a serious concern for one-third of pregnant women, and pelvic pain symptoms impede most daily activities. The cause of low birth pressure during pregnancy is still largely unknown. Despite inconsistent findings, some pathophysiological mechanisms have been explained³.

It is common to experience low back pain (lbp) both during and after pregnancy. The majority of studies indicate that the condition affects at least half of pregnant women. (schoultz, svardsudd, & kristiansson, 1996). It has been reported that 5% to 40% of patients experience persistent lower back pain six months after giving birth⁴.

The location and timing of the worst pain have been linked to pregnancy-related low back pain (lbp). Pregnancy-related and non-pregnancy-related lbp have different characteristics. One third of pregnant women report experiencing severe lbp at some point during their pregnancy, compared to 23.6% of the general population who experience severe lbp. Back pain is most common in the second and early third trimesters of pregnancy⁵.

Pregnancy-related low back pain is a highly common syndrome whose etiology is unknown. It is distinguished by symptoms like back and pelvic pain and disability during pregnancy and the postpartum period. According to studies done on expectant mothers between 1980 and 1990, 78% of them reported having low back pain at some point during their pregnancies, which is more than half of them. As the pregnancy goes on, the pain gets worse and gets in the way of everyday tasks like carrying, wiping down furniture, sitting, and walking. Eventually, the woman has to miss work due to this pain. It can occasionally also interfere with sleep. However, the consequences of it include joint and tendon damage, increased dysfunction, and disability⁶. It is not regarded as a serious health issue. Many expectant mothers view back pain as a typical aspect of pregnancy and believe it will go away on its own after giving birth; as a result, they rarely seek medical attention⁷. According to reports, between 30 and 45 percent of women have low back pain during the postpartum phase⁸. Rehabilitation services support the full physical, mental, social, and intellectual independence of disabled individuals and guarantee their participation in all facets of life⁹. While clinical knowledge is derived from the experience and practice of clinicians, biomedical knowledge is derived from various theories. The process of critical thinking used to synthesize, analyze, and interpret data collected by clinicians from patients or participants, documentation, observations, etc., and apply it to already-existing knowledge is known as cognition¹⁰.  

Literature review
The processes of reasoning and judgment connected to professional practice because it is cognitive, interactive, largely unobservable, occasionally automatic and subconscious, multifactorial, and context-dependent, clinical reasoning is a complex phenomenon. Decisions made by clinicians are prone to error if they lack specific knowledge of their field of work, which is why clinical reasoning in clinical practice is specific to one's area of work¹¹.

A fundamental skill for medical practice is clinical reasoning, which is necessary for making diagnoses and managing patients in a secure and effective manner. The cognitive procedures used by clinicians to identify and treat patients' medical issues are referred to as clinical reasoning (cr). It is defined as a "distinctive, multifarious, and exceedingly intricate ability, distinguished by various methods that access particular information stored in long-term memory. “the range of strategies that clinicians use to generate, test, and verify diagnoses, to assess the benefits and risks of tests and treatments, and to judge the prognostic significance of these cognitive achievements”. Clinical reasoning, according to jones, is an ongoing process that continues throughout the ongoing intervention¹². The process of clinical reasoning is contingent upon an individual's disposition towards critical thinking¹³ and is shaped by their preconceptions, attitude, and philosophical perspective. Clinical reasoning can be thought of as a sequence or spiral of connected, ongoing clinical encounters rather than a linear process. Among these are the rehabilitation problem solving (rps) model for clinical reasoning, three track reasoning, narrative reasoning, pattern recognition, inductive, deductive, and hypothetico-deductive reasoning, as well as the international classification of functioning, disability, and health (icf). But in our clinical practice, we sometimes use these reasoning processes separately and sometimes in combination to arrive at the hypothesis¹⁴.

Hypothetico deductive reasoning is a type of cue acquisition in which related clinical information is recognized. The creation of hypotheses was a crucial step in the problem-solving process after cue acquisition¹⁵. The ability of a clinician to weigh the interpretation of various clinical findings is known as clinical reasoning. In one of the clinical reasoning processes, there are three tracks of reasoning: procedural, interactive, and conditional. These tracks are used to diagnose and guarantee appropriate rehabilitation services based on the needs of the patient and the patient's family. The process of reasoning becomes clearer through examination and interpretation¹⁶.  

Case presentation
Two months after giving birth, a 32-year-old woman with low back and back pain was referred to our clinic. She was gone through normal vaginal delivery. During the time of assessment i found her painful lower back, pain was 8 out of 10 on the verbal numeric scale. Patient reported marked difficulty lifting her child. Every morning she would wake up with significant pain but no numbness or tingling like sensation. The patient reported that the pain started one month before delivery and gradually worsened in the postpartum period. Patient self-prescribed analgesics.

Using clinical reasoning for diagnosis, as a novice practitioner, i am not familiar with this type of cases. I listen patient complains carefully and develop a possible hypothesis. Jones (1992) stated that novice as well as expert practitioner would like to go through some steps while they were dealing with unfamiliar cases. Hypothetico deductive reasoning was the term used for this process.

Cue acquisition
Generally cue acquisition in terms of patient management means collecting as much possible sources in order to make a precise assessment for patients, in fact, cue acquisition means the initial information-gathering stage during the process of clinical reasoning. My patient pain was just only along with the side of injury.

I asked my patient -
1. Which activities of your back provocative pain? Patient said any type of activity.
2. Where is the location of pain or referred pain? Patient said pain occurs in the lower back and thigh.
3. What are the site of pain? Patient said back of the pain and thigh area.
4. How did pain started? Patient said suddenly onset and gradually increased.
5. What are the aggravating factors of pain? Movement, any activity.

Red flag and yellow flag-examiner was asking about vertigo, radiculopathy, tb spine, uterus tumorsudden weight loss, height loss, fever but she does not have anything. Yellow flag was back and thigh pain, activity loss.

The objective assessment (clinical testing) aims to validate or disprove hypotheses generated by the subjective assessment. Posture and gait: adorable posture, spinal percussion or palpation: not important walk on all fours, squat, and stand up. Test for straight leg raising: 80 degrees in both rt and lf tests for motor, sensory, and reflexes are intact.