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9 Articles in Volume 17, Issue #9
Can Physiological Profiles Affect Pain Treatment?
Editorial: Moving Forward from Trump's Opioid Declaration
How Might Pain Practitioners Best Offer Patients Relief Without Pharmacology?
Letters to the Editor: An opportunity to learn what is on the minds of your colleagues and patients
Lumbar Lordosis and Back Pain
Oxytocin, an Opioid Alternative, Ready for Regular Clinical Use to Manage Chronic Pain
Pain, Sleep & Suicide: The Core Role of Interventional Care
Spiritual Factors Impacting a Patient’s Ability to Cope with Uncertainty (Part 3)
The Inter-Connection between Smoking and Opioid Misuse

Lumbar Lordosis and Back Pain

In this case study, the authors review hyperlordosis as a cause of back pain during pregnancy and discuss best practices for pain management before, during, and after pregnancy.

Case Overview

A 26-year-old female, who was 34 weeks pregnant with her first child, presented with lower back pain. She described the pain as a dull ache that was constantly present. While the pain was relieved when she slept on her side with a pillow in between her legs, the patient reported that the pain disrupted her ability to fall asleep. The patient had no other pain complaints or radiation of pain to the legs and had no apparent abdominal issues. The lower back pain disabled her from walking, thereby affected her daily activities and limited her overall quality of life. On physical exam, she was positive for tenderness to palpation over the sacroiliac joint. There was an increased curvature in the lumbar region. When examining the patient’s gait, there was a slight tilt forward, possibly due to her spine’s posterior shift. The patient exhibited no neurological deficits. 

Introduction and Clinical Overview

The female body experiences many changes during a 40-week pregnancy, some of which increase susceptibility to discomfort and pain during pregnancy (see also, “Mechanical changes in pregnancy” on page 32).1 Back arching and a gradual anterior shift may naturally occur with the added load of a fetus’ weight. At the same time, changes in center of gravity and increased body mass may lead to lengthening and weakening of the abdominal musculature.2,3 These combined changes may lead to back pain.4,5 To compensate, the patient may shift the body frequently, leading to changes in posture, which may further induce strain on the spine and perpetuate pain.4

It has been postulated that there are two patterns of common back pain during pregnancy: lumbar pain (LP) and posterior pelvic pain.4 Specifically, the increased mass distribution of the trunk and center of gravity shift may result in lumbar lordosis. This presents as a tilt in the pelvis, which may then result in lumbar hyperlordosis, an inward curvature of the lumbar spine formed by the wedging of lumbar vertebral bodies and the intervertebral disks, which all contribute to LP. Lumbar hyperlordosis is diagnosed by measuring the curvature of the sagittal plane region of the vertebral spine using the Cobb method.

Mechanical changes in pregnancy
Pregnancy is a time of immense biological change during which every system of the body is affected. The physiological and physical adjustments of the female body during pregnancy have vast implications on the level of comfort. For example, the growth of the fetus shifts the center of mass and causes compensatory postural adjustments, which could be responsible for 
the backache commonly reported among pregnant females.1Although there is a strong correlation between back pain and pregnancy, further research is needed to fully understand the physiological mechanisms of this pain.

Normally, slight curves of the spine serve to absorb impact, decrease vertebral stiffness, and enhance muscle function. However, sources of back pain may result from unnatural variations in these sagittal plane curves. The measurement of lumbar hyperlordosis is influenced by multiple factors, such as age, gender, thoracic curvature, and pelvic bend.6

Lumbar lordosis is a crucial factor of sagittal spinal balance. Evidence indicates hat with increased lumbar lordosis, there is a lack of ability of the pelvis to compensate leading to strain.7 Cobb’s is the uniform measurement method and involves measuring the angle between the superior endplate of the first lumbar vertebra to the superior endplate of the first sacral vertebra.8 For an evaluation of lordosis, placing the patient in a standing position using X-rays is common.8 In this literature review, the authors discuss the parameters of lumbar lordosis and its association with pregnancy-related back pain and pain management The study focuses on hyperlordosis as a cause of back pain during pregnancy and discusses management before, during, and after pregnancy.

Prevalence & Risk

Approximately 50% of pregnant patients suffer from some kind of low back pain, such as pelvic girdle pain and LP, during their pregnancies or post-partum period.9 One-third of pregnant women suffer from severe LP, and most women experience LP during their first pregnancy.9 Approximately 80% of pregnant women report that their daily routine is disturbed due to LP and about 10% report being unable to work as a result.9 Managing LP during pregnancy has significant, even life-altering, health-related and economic implications.

Research is warranted to better understand how the pregnant body may compensate when experiencing LP due to the various complications that can arise and so that an appropriate pain management plan can be provided and function restored.

Etiology

As a pregnant woman compensates for changes in center of gravity and body weight, LP may result, leading to increased levels of relaxin and relaxation of the pelvic ligaments. Biomechanical differences play an even larger role, as an anterior shift in the center of mass has been related to women lacking positional adjustment of lumbar lordosis.10

During pregnancy, mechanical interruption of the intervertebral discs occurs in axial loading, leading to a decrease in height and compression of the spine.10 When there is more distance from the hip, the force of gravity may create a large hip movement and destabilize the upper body. Hyperlordotic back pain involves many aspects of the posterior spine from the muscle-tendon units and ligaments to the facet joints.11

Pregnant women may also develop Sway Back posture, where the upper body is displaced posterior to the lower body. This posture, wherein the head moves forward, may increase the tone of neck and back muscles in order to stabilize the thoracic kyphosis but, in turn, places greater stress on the lower back. These postural changes may be especially noticeable during the third trimester due to greater weight gain.10

Risk Factors

Evidence points to several risk factors for low back pain related to pregnancy:12

  • Parity
  • Body mass index
  • History of hypermobility
  • Amenorrhea
  • Prior history of low back pain.

Older age, amniotic fluid index, fetus estimated birth body weight, physical workload, depression, and pain-related catastrophizing have also been found to be risk factors.13

The biomechanical risk factors listed above for causing low back pain during pregnancy are associated with lumbar lordosis, as well. Spinal postural parameters change according to a patient’s lumbar lordosis and may include increased thoracic kyphosis, pelvic orientation, and sacral incidence. Additionally, age, sex, and height may affect lumbar lordosis.14 Heritability, as well as occupational loading, athletic training, and physical fitness, have also been shown to alter lumbar lordosis.14 All of these factors impact individual sagittal lumbar alignment and motion of the lumbar spine as related to LP during pregnancy.15

Patient Education and Preventive Approaches

Lumbar back pain may cause many pregnant women increased distress due to an adverse effect on daily lifestyle and work functionality. Physicians, whether a pirobstetrician/gynecologist, or pain practitioner, are therefore encouraged to provide patient education, exercises that reduce lumbar lordosis, and prenatal care to help prevent this pain.16 It is further recommended that an obstetrician/gynecologist discuss potential changes to the body and share preventive methods with their patients in advance of pregnancy in order to prevent potential lower back pain.

Posture

Women who maintain proper posture may prevent LP by decreasing mechanical stress on the lower back. Physical activities performed in a neutral spine posture can also help with prevention.17 Pregnant women should be advised to avoid bending combined with spinal rotation (such as with vacuuming and mopping). A comfortable sleep position may also be necessary, possibly with the support of a towel roll or cushion at the waist.17

Prenatal Osteopathic Manipulative Treatment

One study found that osteopathic manipulative treatment (OMT), along with prenatal care, improved LP in pregnant women. During OMT, physicians work to alleviate strain placed on muscles by shifts in center of gravity to improve mobility. Techniques to find and relieve restrictions include soft tissue kneading and stretching, myofascial release, balanced ligamentous tension, and adding pressure to different regions to balance the body as a whole, for example.16

If a clinician believes LP may be from a sacral imbalance, which oftentimes occurs in pregnancy, the physician can diagnose the sacrum. Patient follow-up may help determine how involved the sacral dysfunction was in the LP. 8

In a randomized, placebo-controlled trial, participants were treated with OMT from week 30 of pregnancy until delivery. Just over 140 trial subjects were  divided into three cohorts: usual obstetric care with OMT, usual obstetric care with sham ultrasound, and usual obstetric care only. Back pain increased during pregnancy for the usual obstetric-care only cohort and decreased for the OMT group, while remaining the same for the sham ultrasound group (effect size, 0.72; 95% confidence interval, 0.31–1.14; P = 0.001 vs usual obstetric care only; and effect size, 0.35; 95% confidence interval, –0.06 to 0.76; P = 0.09 vs usual obstetric care and sham ultrasound treatment).18

In a meta-analysis reviewing OMT for LP in pregnant women, another study found significant improvement in pain with OMT though low-quality evidence (MD, -23.01; 95% CI, -44.13 to -1.88) and functional status (SMD, -0.80; 95% CI, -1.36 to -0.23), while a third study reported moderate quality evidence in favor of OMT for postpartum LP (MD, -41.85; 95% CI, -49.43 to -34.27).19,20

Acupuncture

Acupuncture has been described as favorable in reducing LP in pregnant women. An 8-week study conducted in Brazil included 61 pregnant women aged 15 to 29 experiencing low back or pelvic pain; subjects were 15 to 30 weeks pregnant. Of those, 27 participants received acupuncture (in addition to usual care) once a week (twice if necessary)  for a maximum of 12 sessions, while 34 participants were in a control group. Using a 0 to 10 numerical rating scale, average pain was reduced by 4.8 points in the acupuncture group (versus -0.3 in the control group) (P  < 0.0001).

In 78% of the participants in the acupuncture cohort, pain decreased by 50% vs in 15% of the control group (P  < 0.0001). Additionally, the acupuncture group reported greater functional ability. There were no reported serious adverse effects, although one participant experienced more pain a few hours after the first session.21

Prognosis & Management

Lumbar back pain may persist up to 14 months postpartum. Women with continuous LP throughout their pregnancy may have a higher likelihood of persistent pain postpartum.22 Women with excruciating pain levels are advised to employ pelvic belts, and/or obtain referrals for osteopathic manipulation, physical therapy, acupuncture, and/or chiropractic care.22

For non-pregnant women, lumbar lordosis treatment generally consists of ice application, nonsteroidal anti-inflammatory drugs (NSAIDs), and physical therapy. For pregnant and postpartum women, treatment may include exercises, abdominal strengthening, and pelvic tilts.23 A physiotherapist may also provide anti-lordotic exercises, and hamstring and thoracolumbar stretches.11

The American College of Obstetricians and Gynecologists has published a pamphlet demonstrating some exercises, which may be helpful in alleviating LP during pregnancy.24, 25

Case Follow-Up

The 26-year-old pregnant patient had low back pain that was inhibiting her lifestyle. At 34 weeks, a very significant part of her pregnancy, including additional weight gain, remained. This period required the most resilience and endurance for the delivery. Our recommendation was to avoid bed rest, and instead, keep the patient mobile.

Pain was dull, presenting over the sacrum and sacroiliac joint. Placing a pillow between her knees during sleep relieved much of her pain, further suggesting that pain was coming from the sacroiliac joints and the involved ligaments. The ligaments were likely being overstretched as she slept in a side position with her top leg pulled toward the bed. Recall that ligaments soften during pregnancy in preparation for delivery. These anatomical structures respond to body changes leading to increased lumbar lordosis as the fetus gains weight in the last few weeks. Maintaining an active lifestyle, despite the extreme stretching, may reduce pain and keep the patient from resorting to a sedentary position.

Gentle osteopathic musculoskeletal treatment was further recommended. Postural adaptations that ensured sleep were crucial to her well being, as were walking and exercise. Treatment was easily addressed based on the knowledge of biomechanics and physiology of pregnancy changes and progression.

Summary

This study outlines the major contributors of lumbar pain in pregnant women. Changes to the female body during pregnancy can have a lasting effect. Since LP may continue into the postpartum period, it is crucial that patients begin abdominal strengthening exercises early in the pregnancy. It may be beneficial to educate patients on expected body changes and preventive methods for reducing LP throughout and after the pregnancy. Physicians may offer treatment options such as osteopathic manipulation, physical therapy, and acupuncture.

Acknowledgements: This project was inspired by a Georgia Tech Biomechanics topic discussion with colleagues Pranaya Chilukuri at the University of Alabama at Birmingham School of Medicine; Katie Neuberger, a clinical specialist at Boston Scientific; and Abigail Riddle at Harvard Law School.

Last updated on: November 9, 2017
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