Lower back pain affects about 69% of pregnant women in the United States, yet studies show that only 32% of those affected report their lower back pain symptoms to their health care providers. A misunderstanding exists as to what can be done to relieve low back pain during pregnancy, not only by patients, but also by many health care providers. In fact, only about 25% of physicians refer patients out for lower back pain treatment during pregnancy when it’s brought up by the patient.
There is often a misguided belief that nothing short of completing pregnancy can or should be done. While it is true that many cases of pregnancy related back pain resolve after completion of pregnancy, health and quality of life during pregnancy can be severely affected. In addition many report a continuation of lower back pain postpartum. In survey studies, as much as 51% and 20% of women reported lower back pain 1 and 3 years later, respectively. This is likely due to unresolved biomechanical changes and imbalances placed on the body during the pregnancy.
The reason for lower back pain during pregnancy is believed to be multifactorial. There are 3 distinct mechanisms known:
- Biomechanical/Musculoskeletal – It is theorized that the additional 25-35 lbs of normal weight gain during pregnancy shifts the center of gravity, increases the stress on the spine and surrounding tissues of the lower back, creates pelvic tilting, and stretches and weakens the abdominal musculature responsible for creating stability in the lower back.
- Vascular – This theory suggests that as the uterus enlarges during pregnancy it can put undue stress on the surrounding vessels (vena cava in particular) and create pooling of fluids around the pelvis and lower back. This is part of the reason why it is not recommended that pregnant women sleep on their back since it would increase the direct pressure on the vena cava.
- Hormonal – Increased relaxin and estrogen to create laxity in the joints of not only the pelvis but also the lumbar spine. This laxity is favored for delivery, but biomechanically, it can can create more stress on the lower back.
Pregnancy related lower back pain, being a special condition, requires safe and effective treatment approaches so as not to cause harm by invasive procedures or drug exposure to the mother and fetus. Conservative care has been shown to not only be safe, but also shows high patient satisfaction rates for the management of lower back pain during pregnancy. Below, is a brief explanation of our approach in the office:
The first step in our office, is to take a detailed history of the nature of the lower back pain, and rule out any red flags, which may point to something other than the 3 distinct known mechanisms of lower back pain during pregnancy. This helps identify those patients who need to be referred out. This is followed by an examination looking at the lower back and pelvis posture, range of motion, and the specific musculature important to lower back and pelvic stabilization. Pain provocation tests are used to identify the areas of the lumbar spine and pelvis which are most involved. From there, we discuss findings, in office treatment options, and safe exercise recommendations that can be used during the different stages of pregnancy.
The question of prevention is important. If lower back pain continues, even after the completion of pregnancy, it stands to reason that biomechanical/musculoskeletal reasons for the pain persist and may have even existed before becoming pregnant. Preventative exercises and care may play an important role in preventing pregnancy related back pain and reducing its impact on daily activities and quality of life during pregnancy.
Works Cited
Gutke, Annelie, et al. “Pelvic Girdle Pain and Lumbar Pain in Pregnancy: A Cohort Study of the Consequences in Terms of Health and Functioning.” Spine, vol. 31, no. 5, 2006, pp. E149-E155.
Matthews, Leslie J., et al. “Orthostetrics: Management of Orthopedic Conditions in the Pregnant Patient.” Orthopedics, vol. 38, no. 10, 2015, pp. e874-e880.
Mogren, Ingrid M. “Previous physical activity decreases the risk of low back pain and pelvic pain during pregnancy.” Scandinavian Journal of Public Health, vol. 33, no. 4, 2005, pp. 300-306.
Noon, Megan L., and Anne Z. Hoch. “Challenges of the Pregnant Athlete and Low Back Pain.” Current Sports Medicine Reports, vol. 11, no. 1, 2012, pp. 43-48.
Östgaard, H. C., et al. “Reduction of Back and Posterior Pelvic Pain in Pregnancy.” Spine, vol. 19, no. 8, 1994, pp. 894-900.
