Low Back Pain and Pregnancy

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Original Editors - Timothy Assi

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Search Strategy

Using PubMed, I combined various terms for searching articles regarding the subject. At first, I found some articles giving specific information concerning low back pain in pregnancy and the epidemiology, risk factors, cause. Later on, I searched for articles including physiotherapy and its treatment. Because there was an overload of information with contradictory studies, it was difficult to exclude some information. I searched for new articles in the references for other relevant studies and visited many libraries for a book on this subject. Eventually I found a few books about low back pain itself, but not really in relation to pregnancy. 

Definition/Description

Pregnancy-related low back pain and/or pregnancy-related pelvic girdle pain (PPGP) are two different common complaints that can occur separately or combined(1). Ostgaard et al. created criteria defining the differences between back pain and posterior pelvic pain – although it is unclear why a distinction is made. Low back pain is situated above the sacrum and mostly provoked when a patient was asked to bend over (forward flexion). He observed decreased motion in the lumbar spine and pain by palpation of the erector spinae. Ostgaard also developed the pelvic pain provocation test to exclude pregnancy-related low back pain from PPGP (2, 3, 4).

Clinically Relevant Anatomy (a)

The lower back region – also called the lumbar region – is part of the spine and consists of five vertebrae. This region has his own specific curvature - the lumbar lordosis, different from the upper thoracic and cervical region. These five lumbar vertebrae are also larger and wider because of their weight-bearing properties. The sacrum and coccyx are situated below the lumbar region. Two important ligaments connect the vertebral bodies of the spine: lig. longitudinale anterior and posterior. These long ligaments are attached to an intervertebral disc between two consecutive vertebrae. Lig. flavum, lig. interspinale, lig. intertransversarium, lig. anterius and posterius are other ligaments that provide stability due to the firm connection between the vertebrae. Furthermore, it is important to observe the functionality of some muscles related to low back pain: back muscles, pelvic muscles and abdominal muscles.

Epidemiology /Etiology

Previous studies (or reviews) investigated the prevalence of low-back pain during pregnancy in various populations. The results seemed very variable, ranging from 24% to more than 89,8%(1,2,5,6,7,8). The international reported prevalence of PPGP - and/or low back pain - in the Netherlands was between 45% and 89%(9).

Characteristics/Clinical Presentation

There is a lack of scientific clarity to the mechanism of this injury, yet there are several possible reasons. During pregnancy, changes occur in the facet joints, back muscles, ligaments and disc, which can affect the stability of the spine and lead to back pain. Increasing weight of the fetus causes a larger abdominal volume, allowing the abdominal muscles to be stretched and impaired (c,10). Static equilibrium interruption of the back and abdomen changes the center of gravity, resulting in posture adjustments and extra mechanical stress on the back (c,11,12). As pregnancy progresses, relaxine concentration rises causing laxity of the lig. longitudinalis and weakening this strong ligament. The concentration of relaxin in women with severe pelvic girdle pain in pregnancy is significantly higher than woman without back pain.(11,13).

Risk factors that increase the complaints were similar in some studies(5,6,9,14): previous backpain history before pregnancy and multiparity. Some authors (7,b) believe that age, weight and height of the mother, fetal weight, the number of pregnancies, etc. are not risk factors, but this stays unclear since there are many studies with contradictory results(2). The prevalence of low-back pain during pregnancy also depends on the moment of pregnancy, which is measured the highest during the third trimester of the pregnancy (8,9).

Differential Diagnosis

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Diagnostic Procedures

To formulate a diagnosis, the patient her history (anamnesis), movement possibilities / limitations and help-request must be known. This will help the physiotherapist understand the patient her health problem and needs. Knowledge of the anatomical and functional disorders, activity limitations and restriction of participation will help the physiotherapist to estimate his role within the physiotherapy. It is important to recognize specific complaints – known as red flags. And if present, contact a doctor. (9)

Different measure instruments can be used in the diagnosis to estimate the complaints more objectively: Visual Analogue Scale (VAS)(d), Roland Disability Questionnaire (RDQ), Impact on Participation and Autonomy (IPA), PHotograph series Of Daily Activities (PHODA), Pain Behavior Scale (PBS).Outcome Measures

Examination

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Medical Management

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Physical Therapy Management

The way of treatment depends on the diagnosis and timing of pregnancy (before or after childbirth). Firstly, the patient should understand her own symptoms and be motivated to remain active. Back care advice(7) and exercise during second half of the pregnancy (15) significantly reduces LBP. Postural education can prevent unnecessary mechanical stress on the back (16), therefore neutral postures during ADL and physical activities are recommended. Stability, coordination and functional preservation should be trained with active back exercises - endurance training for back muscles stabilization (b). Pelvic tilts, knee pull, straight leg raising, curl up, lateral straight leg raising and water aerobics are recommended because it relieves lumbar pain in pregnancy (16).

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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Books

a. I.A. Kapandji. Bewegingsleer deel III de romp en wervelkolom. Bohn Stafleu van Loghum. Houten. 2009; 257 pages.
b. R. Meeusen. Praktijkgids Rug-en nekletsels deel1. Kluwer. 2001;154-56pages
c. J. Dequeker. Chronische lage rugpijn en invaliditeit – rugpijn in gynaecologie. Acco Leuven. 1979; 141 pages
d. M. Ronald, J.R. Jenner. Back pain New approaches to rehabilitation and education. Manchester university press. 1989;258 pages

Articles

1. Endresen EH. Pelvic pain and low back pain in pregnant women – an epidemiological study. Scan J Rheumatol. 1995; 24: 135–41.
2. Bastiaanssen JM, de Bie RA, Bastiaenen CH, Essed GG, van den Brandt PA.A historical perspective on pregnancy-related low back and/or pelvic girdle pain. Eur J Obstet Gynecol Reprod Biol. Maastricht. 2005
3. H.C. Ostgaard, G. Zetherstrom, E. Roos-Hansson and B. Svanberg. Reduction of back and posterior pelvic pain in pregnancy. Spine 19. 1994; pp. 894–900
4. Ostgaard HC, Zetherstro¨m G, Roos-Hansson E. The posterior pelvic pain provocation test in pregnant women. Eur Spine J. 1994;3:258–60.
5. Mogren IM, Pohjanen AI. Low back pain and pelvic pain during pregnancy: prevalence and risk factors. Spine (Phila Pa 1976). 2005 Apr 15;30(8);983-91.
6. Ostgaard HC, Andersson GBJ, Karlsson K. Prevalence of back pain in pregnancy. Spine 1991; 16: 549–52.
7. Orvieto R, Achiron A, Ben-Rafael Z, Gelernter I, Achiron R. Low back pain of pregnancy. Acta Obstet Gynaecol Scand. 1994; 73: 209–14.
8. Noureddin Nakhostin Ansari, PhD, PT, Scott Hasson, Soofia Naghdi, , Sousan Keyhani, Bsc, and Shohreh Jalaie. Low back pain during pregnancy in Iranian women: Prevalence and risk factors. Physiotherapy Theory and Practice, 26(1):40–48, 2010
9. C.H.G. Bastiaenen,E.J.M. Hendriks,A.L. Pool-Goudzwaard,N.T.M. Bernards,M.L. van Engelenburg-van Lonkhuyzen, C.P. Albers-Heitner,J. van der Meij,M.H.M. Grupping-Morel,R.A. de Bie. KNGF-richtlijn, Zwangerschapsgerelateerde bekkenpijn, Nederlands Tijdschrift voor Fysiotherapie,Jaargang 119 · Nummer 1; 2009
10. Wendy L Gilleard, J Mark M Brow.Structure and function of the abdominal muscles in primigravid subjects during pregnancy and the immediate postbirth period. Physical Therapy, 1996; 750-62
11. Robin Russell, Felicity Reynolds. Back pain, pregnancy, and childbirth. British medical journal. 1997;1059-1064.
12. W. W. K. To, M. W. N. Wong. Factors associated with back pain symptoms in pregnancy and the persistence of pain 2 years after pregnancy. Acta Obstetricia et Gynecologica Scandinavica. 2003; 1086-91.
13. MacLennan AH, Nicolson R, Green RC, Bath M. Serum relaxin and pelvic pain of pregnancy. Lancet 1986;243-5.
14. Ostgaard HC, Andersson GBJ. Previous back pain and risk of developing back pain in a future pregnancy. Spine 1991; 16: 433–6.
15. A. Garshasbi, S. Faghih Zadeh.The effect of exercise on the intensity of low back pain in pregnant women. International Journal of Gynecology and Obstetrics.2005; 88, 271—275
16. Jennifer Sabino, Jonathan N. Grauer. Pregnancy and low back pain. Curr Rev Musculoskelet Med. 2008; 1:137–141

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