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Lower back pain during pregnancy: Advice and exercises for women

Article  in  British Journal of Midwifery · September 2010

DOI: 10.12968/bjom.2010.18.9.78064

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 Clinical practice
Lower back pain during pregnancy:
advice and exercises for women
Abstract
Lower back pain during pregnancy can be severely debilitating for some
women, and midwives can provide help and support for this group of
women by providing advice, reassurance and onward referral where
needed.
L
ower back pain during pregnancy is widely
accepted as a consequence of pregnancy, by
women, midwives and doctors. By under-
standing the main reasons why back pain occurs
during pregnancy, women can usually be reas-
sured and are able to help themselves. It is also
important that back pain during pregnancy is not
wrongly diagnosed and/or confused with pelvic
girdle pain (PGP), a term which includes symphisis
pubis dysfunction (SPD) and diastasis symph-
ysis pubis (DSP), a condition which can only be
confirmed by diagnostic imaging.
This may cause confusion for midwives as
European back care guidelines (Vleeming et al,
2007: 20) define PGP thus:
‘Pelvic girdle pain (PGP) is a specific
Yana Richens, form of low back pain (LBP), that can
Consultant Midwife, occur separately or in conjunction
University College with LBP.’
London Hospitals NHS
Foundation Trust Pelvic girdle pain
Pain at the back of the pelvis is known as pelvic
Karen Smith, Sports girdle pain. It is sometimes also called sacro-iliac
Lecturer, Warwickshire joint (SIJ) pain, because that is the name of the
College, Pre/Postnatal joint where problems arise. PGP is often misdiag-
personal trainer nosed as sciatica but only a few women, just 1%,
have sciatica during pregnancy. The prevalence of
Shelia Leddington back pain was studied in 855 pregnant women who
Wright, Senior Lecturer were followed from the 12th week of pregnancy,
Sports Therapy, every 2nd week, until childbirth. True sciatica
Coventry University, with a dermatomal distribution occurred in only
Physiotherapist 10 women (1%). Back problems before pregnancy
and member of increased the risk of back pain, as did young age,
the Association multiparity, and several physical and psychological
for Chartered work factors (Ostgaard et al, 1991).
Physiotherapists in Symphysis pubis dysfunction occurs where the
Women’s Health joint becomes sufficiently relaxed to allow insta-
www.acpwh.org.uk bility in the pelvic girdle. In severe cases of SPD,
the symphysis pubis may partially or completely
562
British Journal of Midwifery. Downloaded from magonlinelibrary.com by Yana Richens on October 20, 2015. For personal use only. No other uses without permission. . All rights reserved.
rupture. Where the gap increases to more than
10  mm, this is known as diastasis of the symph-
ysis pubis. The non-pregnant woman’s symphysis
pubis gap is 4–5  mm and it is normal for it to
widen 2–3  mm, without discomfort, during the
last trimester of pregnancy. This increases the
diameters of the pelvic brim and cavity outlet
to facilitate delivery of the fetus. The average
symphysis pubis gap during the last 2 months of
pregnancy is 7.7  mm with a range of 3–20  mm
(Philipp and Setchell, 1991).
It is therefore important that midwives are
aware of the possible causes of back pain so that
they are able to advise women appropriately and
refer those women who require further treatment
to the correct health professional. This article
focuses on lower back pain during pregnancy
and not PGP. If a midwife suspects that a woman
has PGP, the woman should be referred to an
obstetric physiotherapist for diagnosis and appro-
priate treatment. The European guidelines for the
management and treatment of PGP have made
a list of recommendations for the diagnosis and
imaging of PGP (Box 1).
The guideline highlights that the risk factors for
developing PGP during pregnancy are most prob-
ably: a history of previous LBP, and/or previous
trauma to the pelvis. There is slight conflicting
evidence (one study) against the following risk
factors; pluripara and high work load. There is
agreement that non risk factors are: contraceptive
pills, time interval since last pregnancy, height,
weight, smoking and age (one study reports that
young age is a risk factor).
Low back pain during pregnancy
As highlighted in the antenatal care guide-
line (National Institute for Health and Clinical
Excellence (NICE), 2008), obtaining a clear picture
of low back pain in pregnancy is difficult. This
is mainly a result of the wide variations of low
back pain reported in the literature and low
back pain and pelvic pain are often reported
together. Furthermore, back pain or back discom-
fort during pregnancy is very subjective. The
estimated prevalence of backache during preg-
nancy ranges between 35% and 61%. Among these
women, 47–60% reported backache first devel-
British Journal of Midwifery • September 2010 • Vol 18, No 9

oping during the 5th–7th month of pregnancy.
Symptoms are often reported by women to be
worse in the evening and in the third trimester
(NICE, 2008; Ansari, 2010). In a prospective study
of 200 Swedish women, Kristiansson et al (1996a)
found that 76% reported back pain at some point
in their pregnancy. In a review article, MacEvilly
and Buggy (1996) state that more than one third of
pregnant women find back pain a severe problem.
Pain often increases with advancing pregnancy
and interferes with work, daily activities and sleep.
There are two main reasons for lower back
pain during pregnancy—altered posture and an
increase in the hormone relaxin.
Altered posture
Back pain during pregnancy attributed to an
altered posture is a result of the increasing size
and weight of the growing fetus in the uterus as
the pregnancy progresses; this causes the woman’s
abdominal wall to stretch to accommodate the
expanding uterus. The uterus is normally a pelvic
organ, however, after the first trimester the uterus
expands and becomes an abdominal organ, which
presses forwards onto the abdominal muscles.
This results in altered posture with the increased
lumbar lordosis (exaggerated curvature of the
lower spine), which is necessary to balance the
increasing anterior weight of the womb. The
Abdominal
muscles
Figure 1. Pregnancy can put a strain on the abdominal muscles as well as the lower back
British Journal of Midwifery • September 2010 • Vol 18, No 9
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Clinical practice
Box 1 Summary of recommendations
for diagnosis and imaging of pelvic girdle
pain
To make the diagnosis pelvic girdle pain (PGP) the following tests are
recommended for use during the clinical examination:
ll Sacro-iliac joint (SIJ) pain: posterior pelvic pain provocation test
(P4); Patrick’s faber test; palpation of the long dorsal SIJ ligament;
Gaenslen´s test
ll Symphysis: palpation of the symphysis and modified Trendelenburg’s
test of the pelvic girdle
ll Functional pelvic test: active straight leg raise test (ASLR)
ll It is recommended that a pain history be taken with specific attention
paid to pain arising during prolonged standing and/or sitting. To ensure
that the pain is in the pelvic girdle area, it is important that the precise
area of pain be indicated. The patient should either point out the exact
location on her body, or preferably shade in the painful area on a pain
location diagram.
Source: Vleeming et al (2007)
uterus, including its contents, can weigh over 20
times its non-pregnant weight. Given the current
and ongoing obesity epidemic, it is likely to weigh
more and this weight is supported by the abdom-
inal muscles. In some women, as the pregnancy
progresses the rectus abdominal muscles move
laterally during pregnancy and may remain sepa-
rated during the postpartum period (Gilleard and
Lower back takes on an
abnormal amount of
weight from the torso
563
 Clinical practice

enced posterior perlvic pain, Ostgaard et al (1994)

Box 2 Effects of pregnancy on the spinal found that 83% of these women gained some relief
column from using a support belt.
The natural curves of the spine become more pronounced because of: Women should avoid, where possible, excessive
ll Increased body weight lifting; this could be other toddlers or siblings, so
ll The centre of gravity moving forward women should encourage them to sit on their knee
ll Increased lordosis. when sitting down, rather than lifting them.
Increased stress to the spine causes the pelvis to tip forward resulting in: Finding a comfortable and safe sleeping posi-
ll Poor posture tion is vital in preventing back strain; women
ll Backache should be advised not to sleep on their backs
ll Fatigue. during the later stages of pregnancy. Instead they
Insufficient support from the abdominal muscles may be present should be advised to sleep on the side with pillows
because of: supporting both the abdomen and back with an
ll Poor tone before pregnancy extra pillow between the knees. This will help to
ll Pendulous abdomen caused by frequent pregnancies stabilize the spinal column.
ll Separation of the rectus abdominis.
Skeletal changes are caused by the extra weight gained during pregnancy Increased relaxin
and produce extra work load for the spine. The forward tilt of the A further cause of back pain during pregnancy
uterus into the abdominal cavity produces increased lordosis. The body is the increased production of the hormone
compensates as the pelvis rotates on the head of the femur, moving the relaxin. During pregnancy the body produces
centre of gravity back over the pelvis to prevent toppling forward. Increased relaxin, a polypeptide hormone produced mainly
flexion of the cervical spine and slumping abduction of the shoulders by the corpus luteum, in both pregnant and
leads to pressure on the ulnar and median nerves, producing a carpal non-pregnant women. It rises to a peak within
tunnel syndrome. The enlarging uterus rotates on its long axis to the approximately 14  days of ovulation and then
right resulting in instability and uneven distribution of the pregnancy load. declines in the absence of pregnancy, resulting
Finally, increased weight of breast tissue affects the centre of gravity. in menstruation. During the first trimester of
Source: Baddeley (1999) pregnancy, relaxin continues to rise and addi-
tional relaxin is produced by the decidua. Relaxin
is present in 10  times its normal concentration
during pregnancy. It reaches its peak at 12 weeks
Brown, 1996). Back pain is likely to increase with gestation and then drops to 50% of its peak by
multiple pregnancies and also with multiparity. 17 weeks gestation (Kristiansson et al, 1996b).
In the non-pregnant woman, the abdom- The function of relaxin is to soften ligaments, the
inal muscles are important in maintaining body tough, flexible tissues that connect bones, called
posture. The abdominal muscles are stretched ligamentous laxity (loosening of the ligaments
far beyond their normal state during pregnancy, in the pelvic area). As a result, these joints move
they lose their ability to perform their normal more during and just after pregnancy, enabling
role in maintaining body posture and, as a result, the baby to pass through the pelvis during birth.
the lower back takes on an abnormal amount Relaxin is indiscriminate and also causes abnormal
of weight from the torso. It is clear that the motion in many other joints of the body, resulting
extra weight and strain on the abdominal muscle in inflammation and pain.
(Figure 1) alter the centre of gravity, and pregnant
women may adjust their posture in order to main- Advice midwives can give to help
tain stability. The gravid uterus will also affect the women minimize back pain
spinal column (Box 2). Ideally, the best method of preventing back pain
during pregnancy is to be physically fit, active and
Preventing back pain resulting from altered not overweight before conception occurs. Strong
posture abdominal muscles and a supple and flexible
To help prevent increased back pain during preg- frame will help prevent general aches and pains,
nancy, midwives should advise women on the which may occur during pregnancy.
wearing of appropriate footwear, perhaps with the A Cochrane systematic review (Pennick and
addition of a sacral support belt, to help provide Young, 2007) highlighted effective treatments for
extra strength and stability to the spinal column. women who experience low back pain during
Although there is little evidence for the wearing of pregnancy:
support belts, for some women these bring relief. ll Participating in strengthening exercises
In a study of 407 women, of which 47% experi- ll Sitting pelvic tilt exercises

564 British Journal of Midwifery • September 2010 • Vol 18, No 9

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 Clinical practice

ll Water gymnastics (exercise in water).

These reduced pain intensity and back pain- Urethra
related sick leave better than usual prenatal care
Vagina
alone. The authors of the review concluded:

‘Adding pregnancy-specific exercises, Leg

physiotherapy or acupuncture to
usual prenatal care appears to relieve
back or pelvic pain more than usual
prenatal care alone, although the
effects are small. We do not know
if they actually prevent pain from
starting in the first place. Water
gymnastics appear to help women stay
at work. Acupuncture shows better
results compared to physiotherapy’
(Pennick and Young 2007).

Given these results it could be advisable to

encourage women to undertake pregnancy-
specific exercises during pregnancy. Back muscles
can be safely strengthened during pregnancy
as long as there is no weight from the torso
compressing the pelvis.
Core stability
Core stability has been used as a term in the
fitness industry to describe exercises to prevent
and improve the trunk stability, which is
claimed will prevent and reduce low back pain
(Richardson et al, 1999). Core stability or func-
tional stability can be defined as a result of
multiple factors working in constant interac-
tion and mutual influences (Elphinson, 2009)
or, more simply, is maintaining an efficient,
balanced poise; where the body is stabilized in
the most economical manner for movement and
rest. The pelvic floor and trunk muscles all form
part of the stabilizing musculature.
There are two simple exercises that midwives
can safely give to women during pregnancy—
pelvic floor and pelvic tilting.
Exercise 1 : pelvic floor
First the woman needs to identify their pelvic floor
muscles (Figure 2). She should start this exercise
sitting down and follow the instructions:
ll Imagine you are trying to stop yourself passing
wind and urine. Squeeze the muscles around
your back passage and bladder and hold for up
to 10 seconds. Breathe normally; relax slowly
ll When doing these exercises try not to use
other muscles, for example, by squeezing the
buttocks or thighs together
ll Try not to hold your breath
ll Aim to hold this submaximal (firmly but not
Gluteus maximus
Pelvic floor muscles Anus muscle
Figure 2. Diagram of the pelvic floor
maximal) contraction for 10 seconds and repeat
10 times
ll Repeat 3 times a day.
The exercise can then be incorporated into daily
activities. Contraction of pelvic floor muscles can
be performed in any position, standing, sitting or
on all fours. Strengthening these muscles will take
8–12 weeks.
Exercise 2 : pelvic tiliting
This exercise can be performed in a standing
position:
ll Lean, standing with your back against a wall
with the knees bent softly. Be aware of the
hollow in your lower back area
ll Gently flatten your back against the wall and
become aware of the abdominal contraction
ll Try not to hold your breath; gently and slowly
relax
ll Repeat 5 times.
Try the exercise sitting:
ll Sit tall, like a giraffe
ll Become aware of a hollow in your lower back
ll Flatten and sink your lower spine area and
become aware of your abdominals contracting
as you rock back on your bottom
ll Try to keep the head and shoulders neutral and
breathe normally
ll Slowly return to the starting position
ll Repeat 5 times 3–4 times a day.
Reassure the woman that this exercise will not
harm or squash the baby.

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 Clinical practice
Key points
ll Causes of pelvis girdle pain in pregnancy.
ll Recommendations for diagnosis of pelvic girdle pain.
ll Effects of pregnancy on the spinal column.
ll Advice for exercises in pregnancy.
ll Two key exercises to maintain body poise during pregnancy.
Antenatal pilates and yoga are both good forms
of exercise during pregnancy. Women should be
informed to check that the instructor is qualified
to teach antenatal and postnatal women.
Other methods to reduce lower back pain
in pregnancy
Other ideas have been reported to reduce the back
pain experienced by pregnant women. Midwives
can advise the following:
ll Massage: this soothes tired, aching muscles and
can relax pregnant women (Field et al, 1999).
The woman should lean forwards over the back
of a chair or lie on her side. She should ask her
partner to gently massage her lower back and
the muscles that run either side of her spine. A
trained massage therapist, midwife or a physi-
otherapist may be able to help further
ll Good posture: if she has pain over her coccyx,
she should try not to slump when sitting and
use a small pillow in the lower back area to
support the spine. She should try sitting on a
soft or wedge-shaped cushion or a cushioned
ring
ll Swimming: swimming or aqua-aerobics are
good as the water provides a weightless and
gravity-free environment, which helps relieve
pressure from the joints. Many aqua-aerobic
classes run sessions especially for pregnant
women
ll Acupuncture: it is essential women are advised
to find a practitioner who is trained and experi-
enced in using acupuncture during pregnancy
ll Maternity pillows: these often help support the
gravid uterus
ll Heat and water: a warm bath, a hot pack or a
warm jet of water from a shower head can ease
discomfort
ll Support belts: women often report that these are
extremely helpful despite the lack of research,
as they help take off some of the weight of
the gravid uterus and reduce the strain on the
abdominal and back muscles.
Women must be informed that if they have
severe lower back pain or if the pain persists
they should speak to their midwife or GP, as
566
British Journal of stats
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lower back pain is also a symptom of preterm
labour, or a urinary tract infection.
Conclusion
Lower back pain during pregnancy can be severely
debilitating for some women, and midwives can
provide help and support for this group of women
by providing advice, reassurance and onward
referral where needed.  BJM
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