Low Back Pain and Pregnancy

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Key words: Pregnancy, Manual Therapy, Physical Therapy, Low Back Pain, Exercise

Definition/Description

Low back pain is a common complaint that occurs in 60-70% of pregnancies. (1) It can begin at any point during pregnancy, and approximately one third of these women suffer from severe pain. (2) This is know as either Low Back Pain (LBP) or Peripartum Posterior Pelvic Pain (PPPP). There is limited research available regarding Physical Therapy intervention for pregnant women suffering from Low Back Pain, and for this reason, a homogenous approach tends to be used. As we know, Low Back Pain is not homogenous, and special considerations and precautions should be taken when treating this population. Pregnancy-related Low Back Pain can be defined as pain that is anywhere between the 12th rib and the gluteal folds/pubic symphysis during the course of pregnancy that is not the result of a known pathology such as disc herniation. (3) (4)

Epidemiology /Etiology

The exact etiology of LBP during pregnancy is unknown, but there are known factors that are believed to be contributers. During pregnancy, hormonal changes occur, specifically the release of the hormone Relaxin, which is thought to contribute to ligament laxity, softening of cartilage, and the proliferation of synovium. (2) This causes ligament laxity specifically in the Sacro-Iliac Joint, and the Pubic Symphysis.

Another contributer is the increase in weight which is an average of 25-35 pounds gained during pregnancy. The weight gain increases the amount of force placed across joints, changes the center of gravity, and forces the patient into an anterior pelvic tilt. The anterior displacement of the center of gravity will cause women to shift their heads and upper body posteriorly over the pelvis, causing hyperlordosis of the lumbar spine, which places additional stress on the intervertebral discs, ligaments, and facet joints that can lead to joint inflammation. In addition, abdominal muscles are stretched and weakened, and the added weight can compress on the lumbosacral plexus. There are additional theories that vascular changes may occur during pregnancy, including pressure changes in the vena cava and aorta that lead to water retention, cause hypervolemia, decreased cardiac output, lower the blood pressure and raise heart rate, which can lead to ischemia and metabolic changes, inducing low back pain.

Risk factors for Low Back Pain during pregnancy include a history of LBP during pregnancy, multiple abortions, and smoking. (4)

Also another condition which may occur during pregnancy is called Diastasis Rectus Abominis, which is the separation of the Rectus Abdominis at the Linea Alba, leading to poor posture and LBP. (5)

While values are not known in the United States, in a single year in Sweden, sick leave associated with LBP in pregnancy accounted for $2.5 billion. (9)

Characteristics/Clinical Presentation

The most common onset tends to be during the 5th and 6th month of gestation, and the pain is usually worse later on in the day. 67% of women suffer from pain at night. Factors that aggravate the pain include: standing, sitting, coughing or sneezing, walking, and straining during a bowel movement. During the physical exam, the paravertebral muscles are tender to palpation, the muscles of the back are weak during testing, and there is possible decreased ROM in flexion. The description of the pain is not localized at times, and may be intermittent. It is possible for the pain to radiate down as far as the calf. (4)

Differential Diagnosis

There are other musculoskeletal disorders to consider, including Sciatica, Meralgia Paresthetica, Thoracic/Rib pain, Hip pain, coccodynia, spontaneous abortions, osteomyelitis, osteoarthritis, osteitis condensasn ilii, metastatic cancers, and Diastasis Recti.

Differential Diagnosis for Disc Disease (7)

Morning pain and stiffness, weight bearing, age of the patient, increased abdominal pressure provokes pain, sleep not usually disturbed, eases as day progresses and then gets worse again, history of repeated micro trauma, movement eases pain but not for long (e.g. fidgets), going up hill provokes pain, sitting too long provokes pain especially in low chairs, getting out of a chair provokes pain

Facet Joint Involvement

Non weight bearing, related to movement specifically rotation, pain increased by lateral compression, history of minor injury, pain is not usually referred to an extremity, eases with rest, not affected by coughing or sneezing

Sacroiliac Involvement
There is a definite laterality to pain, pain does not midline, can refer pain to the leg, turning in bed provokes pain, getting out of the car provokes pain, pain is referred to the groin or genitals, pain is related to menstruation prior to pregnancy because of the effects of cyclic hormones on pre-pregnant SIJ ligaments.

Examination

History

Subjective questions:

Have you experienced any complications with prior or the current pregnancy(s)?
Has the physician given any precautions for therapy or exercise?
Do you experience dizziness when lying on your back?
Any lightheadedness?
Is there anything you do that aggravates or eases the pain?

Physical Exam

During an examination of a patient who is pregnant, positioning is a key consideration. Excessive time in supine is not recommended due to the weight of the uterus on the vena cava and vital structures. (7) Examination should include observation of posture and  gait, neurologic screen to rule out underlying pathology, range of motion, muscle tests, palpation, muscle length tests, and assessment of joint mobility. Special tests can include FABER and Trendelenberg.

Due to the level of pain and disability of the patient, and potentially the size of the pregnant abdomen, certain tests and measures may need to be modified for this population.

Modified Tests: (6)

Hip Flexor Length: To modify the test position, have the patient sit on the edge of a table or mat, and extend the test leg as much as possible, while maintaining slight knee flexion. The pelvis should be kept in a neutral alignment. The examiner in one case study assumed that if the patient had normal flexibility, she would able to extend her hip perpendicular to the floor.

SI Joint Examination: The reliable test for measuring symmetry of the ASIS’ is in standing, but if the patient is unable to stand, a modification is to have the patient lying in supine, and have them perform a pelvic bridge. The purpose of the bridge is to align the pelvis in neutral, and then the ASIS’ can be palpated for symmetry in supine.

Innominate Torsion: The modification for this test is done in long-sitting. First, the patient was positioned in supine, and the medial malleoli are palpated, looking for discrepancies in length. Then, the medial malleoli are examined again in long-sitting, to see if there is any shortening of either leg .

Diastasis Recti Test: Position patient in hooklying, and have the patient lift the head and shoulders, and reach for their feet. Palpate the patient’s linea alba, and measure width of separation with fingers. One to 1.5 finger width separation is normal. Either two to 2.5 fingers or observation of a bulge at midline is considered abnormal, and the PT should exhibit caution with any intervention.

Medical Management (current best evidence)

As a physical therapist, it is important to ask the patient if they are having regular check ups by their obstetrician, and if they have any contraindications regarding exercise. A variety of precautions should be taken to manage LBP during pregnancy. Some interventions include: encouraging sidelying while sleeping (can be assisted by using a wedge-shaped pillow), using compression socks to promote venous return to the heart and reduce edema, support belts, soft tissue massage, acetaminophen use if approved by MD (NSAIDs are contraindicated).

While further researcher is needed, the use of support belts has preliminarily been shown to be an effective tool for decreasing pain intensity, duration and effect on ADLs. One such belt is The Loving Comfort support belt which is covered by Medicaid. (7)

Precautions include: Avoiding heavy lifting, holding breath while performing exercises, no moist heat on lower back, ultrasound, and electrical-stimulation.

According to the American College of Obstetricians and Gynecologists, exercise should be avoided if the following signs or symptoms are experienced:

Vaginal bleeding, dizziness or feeling faint, increased shortness of breath, chest pain, headache, muscle weakness, calf pain or swelling, uterine contractions, decreased fetal movement, fluid leaking from the vagina. (4)
 

Physical Therapy Management (current best evidence)

Managment includes specific interventions to address pain, weakness, and mobilty in the pelvic girdle and low back region. After reviewing the research, common interventions that were found to be effective included: two maual therapy techniques and three therapeutic exercises.

Manual Interventions:

Posterior/Anterior Mobilizations in Sidelying to address pain and mobility (Grades 1-4).

Muscle Energy Technique by resisting hip flexion while stabilizing the sacrum (to correct anterior innominate rotation)

Exercises:

Strengthening gluteus medius with clams in sidelying position.

 

Abdominal Drawing in Maneuver sitting on physioball. Can progress exercise by combining ADIM with lower extremity marching.

Latissimus dorsi pull-downs with glute sets to increase the strength of the posterior oblique sling mucles, which compress the SIJ.

Aerobic exercise: Walking, swimming, recumbent bicycle (or nustep), at a low to moderate intensity. The stress on the back should be minimal.

Key Research

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Resources

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Clinical Bottom Line

Many pregnant women experience low back pain. Key questions must be asked and special modifications must be made with physical exam and treatment. Therefore, as patient centered practitioners, it is our job to research and implement evidence based practice to increase outcomes with minimal number of treatments with this special population.

Recent Related Research (from Pubmed)

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References

Special thanks to Jennifer Stone, PT, DPT

1. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy. Spine. 2005;30:983-991.
2. Hall J, Cleland J, Palmer J. The Effects of Manual Physical Therapy and Therapeutic Exercise on Peripartum Posterior Pelvic Pain: Two Case Reports. Journal of Manual and Manipulative Therapy. 2005;13(2): 94-102
3. Gutke A, Kjellby-Wendt G, Oberg B. The inter-rater reliability of a standardised classification system for pregnancy-related lumbopelvic pain. Manual Therapy. 2010; 15: 13-18.
4. Sneag D, Bendo J. Pregnancy-related low back pain. Orthopedics. 2007; 30: 839-845. 
5. Jeffcoat H. Exercises for low back pain in pregnancy. Int J Childbirth Educ. 2008; 23: 9-12. 
6. Cullaty M. Suspected Sacroiliac Joint Dysfunction: Modifying Examination and Intervention During Pregnancy. Journal of Women's Health Physical Therapy. 2006; 30(2): 18-24
7. Sandler
8. Carr C. Use of a maternity support binder for relief of pregnancy-related back pain. JOGNN. 2003; 32: 495-502.
9. Noren L, Ostgaard S, Nielsen TF & Ostgaard HC. Reduction of sick leave for lumbar back and posterior pelvic pain in pregnancy. Spine. 1997; 22: 2157-2160.
10. Huber L. Pelvic Pain in Pregnancy. Cinahl Information Systems. 2009.
11. Freyder SC. Exercising While Pregnant. JOSPT. 1989; 3: 358-365