Low Back Pain and Pregnancy

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

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 specifically causes ligament laxity in the Sacro-Iliac Joint, and the Pubic Symphysis.

Another contributer is the average of 25-35 pounds of weight that women gain while pregnant, which increases the forces 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 will place 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 weight can compress on the lumbosacral plexus. There are additional theories that vascular changes that occur during pregnancy, including pressure changes in the vena cava and aorta that lead to water retention, cause hypervolemia, decreased cardiac output, lowers the blood pressure and raises heart rate, which can lead to ischemia, metabolic changes, which can induce Low Back Pain.
Risk factors for Low Back Pain during pregnancy include a history of LBP during pregnancy, multiple abortions, and smoking. (4)

A condition called Diastasis Rectus Abominis, which is the separation of the Rectus Abdominis at the Linea Alba, can lead to poor posture and LBP. (5)

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 (8)

Morning pain and stiffness, weight bearing component, 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

Not weight bearing, related to movement specifically rotation, does not like lateral compression, history of minor injury in relation to major symptoms, pain is not usually referred to an extremity, eases by rest, not affected by coughing or sneezing

Sacroiliac Involvement
There is a definite laterality to pain, pain does not cause 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 igaments.

Examination

History

Subjective questions:

-Have you experienced any complications with prior pregnancies?
-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

Examination on a patient who is pregnant should include observation of posture and gait, a neurologic screen to rule out red flags, range of motion, muscle tests, palpation, muscle length tests, and assessment of joint mobility. Special tests can include FABER, Trendelenberg.

Due to the level of pain and disability of the patient, and potentially even the size of the pregnant abdomen, certain tests and measures may need to be modified for this population. Also, excessive time in supine is not recommended due to the weight of the uterus on the vena cava and other structures. (7)

Cullaty: Primary measures of impairment used were pain and joint symmetry

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, which maintaining slight knee flexion. The pelvis should be kept in a neutral tilt. The examiner in the 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 that can be done 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.

Innominate Torsion: The modification for this test is done in long-sitting. First, the patient was positioned in supine, and the medial malleoli were palpated, looking for discrepancies in length. Then, the medial malleoli were examined again in long-sitting, so 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 with fingers. One to 1.5 finger 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)

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, soft tissue massage, acetaminophen use if approved by MD (NSAIDs are contraindicated).

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.
 

Physical Therapy Management (current best evidence)

Manual Interventions:

Posterior/Anterior Mobilizations in Sidelying (Grades 1-4).

Muscle Energy Technique for resisted hip flexion (to correct anterior innominate rotation)

Exercises:

Strengthening gluteus medius with clams in sidelying position.

Strengthening gluteus maximus in sidelying with theraband.

Abdominal Drawing in Maneuver (for Diastasis Recti) in sitting. Can progress to ADIM while sitting on physioball with lower extremity marching.

Latissimus dorsi pull-downs with glute sets.

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

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Recent Related Research (from Pubmed)

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References

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1. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy.
Spine. 2005;30:983-991
2. The effects of manual…
3. Gutke
4. Sneag
5. Jeffcoat
6. Cullaty
7. Stone
8. Sandler