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Curr Rev Musculoskelet Med (2008) 1:137–141

DOI 10.1007/s12178-008-9021-8

Pregnancy and low back pain
Jennifer Sabino Æ Jonathan N. Grauer

Published online: 26 February 2008
Ó Humana Press 2008

Abstract

Back pain is ubiquitous in today’s society

and
is particularly common during pregnancy. There are
multiple factors contributing to these symptoms during
pregnancy including pelvic changes as well as alte
rations
to loading. Potential imaging modalities are limited dur
ing
pregnancy due to the desire to limit ionizing radiati
on
exposure to the fetus. Treatments are generally cons
ervative, exercise-based interventions and alternative
modalities may also be considered. Low back pain
associated with pregnancy does generally resolve postpartu
m.
Keywords

Spine Á Prengancy

Introduction
Back pain is a common complaint of pregnant wo
men.
This is generally characterized as axial or parasagittal
discomfort in the lower lumbar region and is musc
uloskeletal in nature. This can be due to a combinati
on of
mechanical, hormonal, circulatory, and psychosocial
factors. Treatment options are often poor, as the cause of ba
ck
pain is not always fully understood. Furthermore, tre
atments that are available usually have a low success ra
te and

consist mainly of life style adjustments and bed res
t.
Discomfort in this region may also be contrib
uted to
changes in the posterior pelvic region, particul
arly the
sacroiliac joints which undergo changes during preg
nancy

J. Sabino Á J. N. Grauer (&)
Department of Orthopaedics and Rehabilitation, Yale Univers
ity
School of Medicine, P.O. Box 208071, New Haven, CT 065208071, USA
e-mail: jonathan.grauer@yale.edu

Approximately 70% of women will report low back pain at some point in their lives [1]. Approximately 10% of women claim that it preve nted them from working [11] and more than 80% report that it a ffects their daily routine including housework. childrearing. Increased body mass index (BMI) may be a risk fact or but study results are conflicting. posterior pelvic pain usually does not extend beyond the knees. 61. in most cases. Mens et al. A sedentary lifestyle increases risk of back pain compared to patients who engage in a more active lifestyle.5 billion in 1990 [12].and/or stretch direct stretch of intrapelvic structures. who found a mean pre and Incidence Back pain can affect women of child bearing age whether pregnant or not. respectively. in th ose who had low back pain compared to BMIs of 23.56 in those who did not [3]. a nd job performance [7]. low back pain resolves itself quickly after partum and does not cause any lasting issues. lumbar and pelvic. Morgen et al.57 and 30. 8]. in this study up to 20% of women claimed that pain started as early as 16 weeks with some claiming pain within the first month [3]. However. less common causes such as infection and preterm labor must be considered expeditiously to avoid serious consequences. Orvieto et al. Curr Rev Musculoskelet Med (2008) 1:137–141 end BMI of 24. Approximately one-third of pa tients report that pain increases as the day goes on while another one-third report that the pain worsens during the night and often disturbed sleep [2]. Nonetheless. Along those sam e lines. if discomfort is persistent or not of classic presentation. They are also more likely to h ave severe and long lasting pain [6].1 weeks. patients who have occ upations described as ‘mostly active’ and ‘physically demanding’ also have a higher risk of developing pain during pregnancy suggesting that extremes of activity are probably not ideal. Etiology . Nore´n et al. This can manifest itself in the lumbar region and/or radiate to the buttocks and posterior thighs. Fortunately. Activity is also related to the onset of back pain durin g pregnancy [3. the incidence of back pain is reported by 50–80% of women [2. This discomfort most commonly starts between the fifth and seventh month of pregnancy [2]. fo und no significant difference between BMI before pregnanc y in those with back pain and the general popu lation [7]. Such discomfort can have a substantial impact on life during pregnancy and may be of variable intensity and duration. In a study by Stapleton et al. with an estimated cost of $2. during pregnancy alone. These results agree with those found by Mogren et al. 138 Women with previous lumbar problems or chronic bac k pain conditions are more likely to develop back pain du ring pregnancy. However. 9% claimed they were completely disabled by pain [5]. with pain occurring twice as often as in those with no prior complaints.8% of women who reported low back pain during pregnancy claimed the pain was at least moderately severe. However. 3]. women who experience back pain during one pregn ancy have an 85% chance of experiencing back pain du ring a subsequent pregnancy [7].10. reported a mean gestation age at start of pain of 22.30 and 28. Pain and associated sy mptoms may be constant or may only occur in certain positi ons or after extended activity. Younger age and multiple parity also increase t he incidence of back pain [3. However. Unlike radiculopathy. Associated symptoms include stiffness and limited motion in the back or legs. The classic description of pain felt by most women is usually a result of symptoms of both types of low back pain. 10]. report back pain as the lead ing cause of sick leave during pregnancy in Scandinavi an countries. One-third of pregnant women claim that low back pain is a significant problem [4]. found that BMI was significantly higher in those who experience pai n compared to those who did not [9].

postural changes the lower back to support the majority of the increased may weight of the torso. Stu longer to recover from activity related compression [15]. discomfort may result particularly not only in the sacroiliac joint but also generalized over the entire lower back. This clearly shifts the spines of pregnant women with low back pain compress the more after activity than pregnant women without back pain body’s center of gravity anteriorly and increase and those who are not pregnant. dies The abdominal muscles also stretch to accommodate the suggest that an anterior shift is associated with expanding uterus. particularly at night when the patient is lying down. particularly abdominal strength. caused by herniation or bulging of an intervertebral disc resulting in nerve compression is often thought to be the cause of low back pain. This suggests that some pain may be secondary to hormonal changes rather than physical stresses. As the structures of the pelvis and lower spine soften and become more pliant.99 mm. they lose their ability to pubic perform the function of maintaining body posture. and muscular endurance. 4. It has been suggested that the hormone relaxin increases 10-fold in concentration during pregnancy. 139 Factors such as degenerative disc disease. The expanding uterus presses on the vena cava. Rodacki et al. Hormonal changes during pregnancy also cause inflammation and pain in the back. A significant portion of women first experience pain during the first trimester. and increase in the natural inward curvature of the many changes in load and body mechanics th spine. Pregnancy relat ed problems may also develop such as preterm labor and . Furthermore. is the result of venous engorgement in the pelvis. causing symphysis problems. when mechanical changes do not yet play a significant role in the etiology of pain [3]. Fast et al. some studies have found back pain to correlate with increased levels of relaxin which are produced during pregnancy [17] even though others have not [18.23.Low back pain in pregnancy is generally ascribed t be implemented to balance the anterior shift. like leg pain and faulty bladder control. This combined with the increased fluid volume from fluid retention during pregnancy leads to venous congestion and hypoxia in the pelvic and lumbar spine. Another theory has been put forward that low back pain during pregnancy. during pregnancy this is very unlikely and only presents in about 1% of pregnant women. showed that 20 and 40 pounds during pregnancy. Sciatica. It is normal to gain betwee expelling fluid. resulting in decreased height and an overall n compression of the spine [14]. For example. further increasing stress on the lower back [13]. maligna ncy. Pregnant women with low back pain also take moment arm of forces applied to the lumbar spine. at occur The intervertebral discs respond to axial loading by during the carrying of a child. flexibility. and infection are all potential causes. Associate d symptoms of pregnancy. 4. However.57. 19]. As they stretch. demonstrated a decrease in postural changes and severity of pain in the exercise group [16]. and 3. can point to this diagnosis. with those involved in no exercise program. Studies comparing pregnant women enrolled in an exercise program designed to address core strength. the respectively. especially pain that worsens at night and is severe enough to wake the patient up. leading to o the lordosis. correlated this condition to the low back pain experienced at night in patients with congestive heart failure [20]. Curr Rev Musculoskelet Med (2008) 1:137–141 Back pain can also be caused by all of the normal fa ctors associated with back pain in the non-pregnant population.

The posterior p elvic pain provoking test. standing on one leg. imaging tech niques are available for consideration. Physical exam can distinguish posterior pelvic pain f rom lumbar pain by several maneuvers. Each test manipulates the patients’ legs to put pressure on the pelvic joints. The effect of absorbed . and Patrick Fabere test elicit pelvic pain. While this scale is used prima rily to measure disability from nondescript low back pain not related to pregnancy. Studies show th at both methods are effective in diagnosing posterior pel vic pain and distinguishing among the various causative sy ndromes. Van De Pol et al. although pain provocation tests are more rel iable than topography/palpation tests [25]. it can be adapted to use for pregna ncy related pain [21–23]. pubic symphy sis. and gluteal regions distinguish pelvic pain from t enderness over the back above the waist. These causes pres ent a more serious problem that can significantly endanger the health of the mother and fetus if not dealt with quickly. Several studies have attempt ed to develop a system to evaluate the extent and effect of p ain specifically during and after pregnancy. Diagnosis Diagnosis of low back pain is usually based on sympto ms because there are few tests available to aid in dia gnosis because of fear of harming the fetus. When the source of the problem is difficult to dete rmine by history and physical alone. Pal pation over soft tissue of the sacroiliac. The amount of radi ation or Grays depends on the type of imaging technique u sed and the area of the mother exposed. Disability as t he result of pain is often measured using the Quebec back pain disability scale.pregnancy induced osteoporosis. developed the Pregnancy Mobility Index (PMI) to ass ess the ability to do normal household activities on a scale from ‘no problems performing this task’ to ‘performing thi s task is impossible or only possible with the aid of others . Evaluation o f low back pain during pregnancy is difficult because the pain is subjective and usually the result of a combina tion of problems. Classic mobility models cannot be applied to pr egnant women because their mobility pattern and expectations are different from the general population. Pain is most often measured on a horiz ontal visual analogue scale from 1 to 100 with anchors at ‘no pain’ and worst pain imaginable.’ The PMI was found to be a valid assessment of mobility during and after pregnancy [24].

Back-pain-reducing programs involving exercise and education are often implemented early in pregnanc y to combat occurrence or increased intensity of pain. curl up. pharmacological treatment. Of the women who saw a physician. a dose of less than 10 cGy poses no increased risk of abnormalities. While instruction may be enough to alleviate the pain. acupuncture. back. One-third of the populati on of the United States use such alternative therap ies. Exercise during the second half of pregnancy significantly decreases pain following a three time a week 12 week program [29]. foun d no significant difference in the prevalence of back pain or resulting functional limitations in pregnant women enrol led in an interventional exercise class and those who rema ined sedentary [16]. Support belts and corsets are another means to support the back. as a result. Similarly. or chest are done with proper shielding. the fetus does absorb a moderate to high amount of radiation when imaging the lumbar spine. The most popular the rapies include massage. acupuncture or chiropractic treatment. including some alternative therapies. lateral straight leg raising. Dumas et al. Midwives (93%) are more likely to recomm end alternative treatments than physicians (64%) or prenatal nurse educators (57%) [34]. other studies contradict these findings. Low intensity exercise can also alleviate pain once it develops. The mean fetal exposure for a conventional lumbar spine radiograph is 1. Proper posture is essential for the relief of low back pain. and pelvic muscles. braces are available to insure proper body positioning.4 and 8. Pelvic girdle belts are used to press together the articular surfaces of the sacroiliac joints to provide st ability . However. However. and prevents prolonged postpartum back pain [11. Pelvic tilts are particularly effective in relieving lumbar pain. Water aerobics is another recommended str ategy that has shown to reduce pain and. straight leg raising. respectively [26]. the nee d for sick leave in women with lumbar pain during preg nancy [30]. the majority of whom are women of childbearing a ge [33]. Treatment options include physiotherapy. and stabilization belts. Magnetic resonance imaging is the preferred technique for severe low back pain that is not relieved with more conservative therapy during pregnancy. which improves posture and allows increased weight bearing ability. 31] and recurrence at 6-year follow-up [32]. Exercise before and early in pregnancy can strengthen abdominal. it is no surprise that alternative therapi es are a popular option for pain relief. head. Only about 50% of women visit a physician for low back or pelvic pain. When treatment is sought. At 2– 8 weeks.radiation depends on gestational age of the fetus. relaxation. The majority of treatment strategies center on prevention because treatment late into the pregnancy is often difficult to implement. Treatment Most women consider back discomfort as an inevitable part of pregnancy and do not seek treatment from a health care 140 also successful in relieving low back pain in preg nant women. After 15 weeks there is a measurable increase in the risk of cancer with an exposure as low as 1 cGy [27]. yoga. Knee pull. From 9 to 15 weeks. although such treatments typically do not have a high incidence of success. conservative management of low back pain is preferred during pregnancy for obvious reasons. S ome studies show that such interventional therapy re duces intensity and anxiety. The majority of women treated report more than one type of treatment [8]. 70% were treated. Women who rate their pain higher on a VAS are more likely to see a physician. over 90% of p renatal health care providers would recommend som e kind of nonpharmalogical treatment. risks are similar and increase with dose. transcutaneous nerve stimulation. while the risk of anomalies increases 1% per 10 cGy increase [26]. decreases the amount of sic k leave taken. and the Kegel exercises are Curr Rev Musculoskelet Med (2008) 1:137–141 Studies have shown that complementary and alt ernative medicine therapies can be an effective means of de creasing back pain during pregnancy.7 mGy with a maximum dose of 10 mGy while the mean and maximum dose for computed tomography is 2. The fetus is exposed to virtually no radiation when radiographs of the extremities. professional. and chiropractic procedures.6. Consequently. Uroradiologic procedure occasionally preformed for hydronephrosis in pregnant women result in a mean uterine dose of .4 mGy [28].

However. some will cause lasting probpelvic belt is often the most prevalent therapy. A drawal in the newborn.9% able complained of continuous pain [38]. in a retrospective study only 10–25% of women daily dosage in a woman with severe back pain d with chronic back pain claim that their first incidence of ue to pain occurred during pregnancy. physicians us body mass index greater than 25 pre-pregnancy. Jansson PO. Ducommun EJ. low back pain is a significant distressing factor to pregnant women and should not be ignored as a normal consequence of becoming pregnant. low back pain can be the normal result of a multitude of mechanical. While most low back pain will relieve itself A within 6 months of partum. 36]. Spine 1987. back pain during pregnancy should be taken seriously by patients and physicians. Spine 1990.and decrease laxity in the pelvis. joint hyper-mobility. Svensson HO. Studies have shown that the Persistent postpartum back pain.12:368 –71. The most common complaint of pregnant women. Pohjanen AI. 3. Muscle relaxants can also be prescribed. Bouklas T. Mogren IM. 20% of women who reported back pain during Opoid medications can be prescribed for severe pregnancy claimed that they still experienced pain [39]. Low back pain and pelvic pain du ring . Whatever the cause. Andersson GB. Application of a Comfortable shoes without heels reduce symptoms and pelvic allow for more motility. most women use an at home approach with support belts. However. 36. ended an pregnancy and 6 months after pregnancy is also a predisepidural administration instead of an oral route to mini posing condition for continuing low back pain [13. hormonal. belt in a high position was found to significantly decreas e pelvic laxity using Doppler imaging of vibration in Outcomes the prone position [35].15:371–5. More vigorous treatment is available for serious problems. indicating that persistent multiple herniated discs [37]. and vascular changes associated with pregnancy. women do not rate it as the most effective therapy avail The majority (36. Curr Rev Musculoskelet Med (2008) 1:137–141 References 1.2%) had recurrent pain while only 6. found that of 464 subjects ough approximately 40% had pain 6 months post-pregnancy. Fast A. problems after pregnancy are often linked to previous Simple home remedies such as heating pads and ov conditions [1. mize However. pregnancy. especially younger Care must be taken to limit the dose to avoid opoid wit than 20 years. T he relationship of low-back pain to pregnancy and gynecolog ic 141 factors. pain. A history of back pain. Physical therapy and fitness programs are available to prevent back pain and alleviate pain if it already exists. nancy. Shapiro D. heating pads. In one case. alth lems. A number of serious pathological processes could be involved endangering both mother and fetus. 41]. is significantly linked to symptoms during pelvic belts have been effective in relieving pain [7. 2. Treatment options for low back pain consist mostly of postural education and rest. Aceta minoSummary phen is an acceptable over the counter medica tion to Low back is a common problem for all women but there is relieve pain during pregnancy while aspirin and ibuprofen an increased incidence of back pain associated with pregare not. Floman Y. and an earlier onset of hpain are associated risk factors for prolonged symptoms. Hagstad A. either recurrent or conuse of tinuous. and postural pillows. while usually regarded with a laissez-faire attitude. study. In a 3-year follow up [8]. younger age. er the counter pain medication can also ease pain. Mogren et al. Low back pain in pregnancy. Alternative therapies are becoming more and more popular in the pregnant population as a safe means to combat pain. 40]. Friedmann LW.

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