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10 Articles in Volume 12, Issue #6
Carpal Tunnel Syndrome
Case Studies in New Daily Persistent Headache
Hormone Testing and Replacement in Pain Patients Made Simple
Management of Prenatal Low Back Pain
Managing the Diabetic Patient with Dementia
Myofascial Pain Syndrome: Uncovering the Root Causes
New Tools for Improving Patient-to-Physician Communication in Clinical Practice
Suicide and Suffering In the Elderly: We Must Do Better
Three Cases Highlight the Challenges Of Treating Rheumatoid Arthritis
Understanding the Sources of Morphine

Management of Prenatal Low Back Pain

Clinical benefits of exercise and osteopathic manipulative treatment include improving back pain and minimizing the decline in functioning associated with low back pain during the third trimester of pregnancy.

Case: Prenatal Lower Back Pain

A 28-year-old woman who is pregnant for the first time and has not yet delivered presents at 34 weeks gestation with an achy, stiff pain in her low back (6 out of 10 on visual analog scale). The pain, which does not radiate anywhere, began several weeks ago and has been progressively worsening throughout her third trimester of pregnancy. She notices mild improvement when lying on her side with her hips bent.

Physical exam is positive for tissue texture changes over L3-L5 vertebrae, tenderness to palpation over the lumbar paraspinal muscles, left-side pain at the sacroiliac joint, and limited range of motion of the left hip.

 

It is estimated that 25% of pregnant women will experience, at least temporarily, some disability related to musculoskeletal pain.1 Pregnancy-related back pain may result in sleep disturbances and may affect the quality of life for these patients.2-4 The good news is that there are a number of management options to ease back pain—including tips from the American College of Obstetricians and Gynecologists (ACOG), exercises, acupuncture, medications, and osteopathic manipulative treatment (OMT). It has been shown that the use of OMT during the third trimester of pregnancy has clinical benefits in improving back pain and minimizing the decline in functioning associated with low back pain. This article will review the use of osteopathic treatment in pregnant patients.

Musculoskeletal Changes During Pregnancy
During pregnancy, there are normal physiological changes that occur in response to weight gain and hormonal changes. On average, pregnant women may gain 25 to 35 pounds.5 This can cause the force across some joints to increase up to two-fold.2 Additionally, because the enlarged uterus causes a change in the patient’s center of gravity, her spine needs to compensate. In order to do so, there will be an exaggerated lordosis of the lower back, forward flexion of the neck, and downward movement of the shoulders.5 The abdominal muscles help to support the core. Weakness and stretching of these muscles will put more strain on the paraspinal muscles affecting the patient’s posture as well.5

Changes in the pelvis and sacrum may be construed as low back pain. In order to prepare for delivery of the fetus, there is a widening and increased mobility of the sacroiliac joints and pubic symphysis.5 There is a significant increase in the anterior tilt of the pelvis, where greater use of the hip extensors, abductors, and ankle plantar flexor muscles is required.6 Furthermore, stance is widened in order to maintain stability of the trunk during movement.3

Hormonal changes during pregnancy also have musculoskeletal consequences. Relaxin is a hormone produced by the corpus luteum, decidua, and placenta. Its concentration peaks during the first trimester to assist placental implantation and growth. Then later in pregnancy, relaxin contributes to separation of the pubic symphysis, relaxation of the myometrium, and softening of the cervix.4 It has been thought that the release of relaxin contributes to joint laxity in various ligaments. This may lead to some instability of the lumbar spine anterior and posterior longitudinal ligaments, leaving a patient susceptible to further lumbar strain. However, other factors may contribute to joint laxity of the extremities. In a study of 35 women, 19 women (54%) demonstrated a ≥10% increase in wrist laxity from the first to third trimester; however, the finding did not correlate to the levels of relaxin.7 Joint pain has been associated with increased estradiol and progesterone levels; thus, it could be possible these hormonal changes are contributory, although further research is needed.

Causes of Low Back Pain
In a survey of almost 1,000 pregnant women, 41% reported a first occurrence of back pain during pregnancy.8 However, back pain is more common in women who have had preexisting back pain, pain during a previous pregnancy, advanced maternal age, and multiparity.9

Most cases of back pain during pregnancy are due to mechanical factors from altered posture, muscle weakness, joint laxity, and/or vertebral facet joint irritation.9 Additionally, patients with preexisting degenerative spondylolisthesis may have aggravated symptoms during pregnancy, especially in the L4-L5 level of the lumbar spine.10 Despite common misconceptions, disc herniation is rarely a cause of low back pain in pregnancy.11 About 10% of nonpregnant women of childbearing age without back pain have asymptomatic disc herniation and about 40% have disc bulges that can be seen on magnetic resonance imaging.12 The incidence of these abnormalities, such as disc herniation, is similar in nulliparous nonpregnant, multiparous nonpregnant, and pregnant women.13 Therefore, disc herniation is not considered in the etiology of low back pain directly related to pregnancy.

When a pregnant patient presents with low back pain, one must consider both lumbar causes and pelvic or sacroiliac causes. This can be accomplished with a good history and physical examination. In general, back pain can present at any time during pregnancy, but is most prevalent in the second half and may be described as pain that is aggravated by activity and relieved with rest. The patient may state that the pain begins in the lower back and radiates down the posterior thighs or even the lower abdomen and anterior thighs.14 Physical examination can help to differentiate between lumbar and sacral origination of the pain. Lumbar pain is characterized by pain above the sacrum. It is accompanied with decreased range of motion at the lumbar spine and pain may be exaggerated with forward flexion at the waist.15 In contrast, sacroiliac pain is worse with extension and external rotation of the hip on the affected side. Pain may be elicited in the sacroiliac joint by the iliac compression test with the patient lying supine.15

Pelvic pain may present similar to low back pain and may originate from the pelvic girdle or secondary to pubic symphysis separation. Posterior pelvic girdle pain is related to the sacroiliac joints. It is described as a stabbing pain in the buttocks distal and lateral to L5-S1, may radiate down to the knee, and may be worse when weight bearing on the ipsilateral leg. This pain may be assessed with the posterior pelvic pain provocation test. This is done by having the patient lie supine, flex the hip to 90°, and exert pressure on the knee down towards the hip while stabilizing the pelvis with a hand on the contralateral anterior iliac spine.16

Whatever may be the cause of back pain during pregnancy, a number of treatment options are available varying from medical management, like acetaminophen and corticosteroid injections, to more conservative approaches including exercises for stretching and strengthening, physical therapy, acupuncture, mechanical bracing for stability, and OMT.

Osteopathic Manipulative Treatment
OMT may complement conventional obstetric care throughout various stages of pregnancy to help relieve the effects of somatic dysfunction, including back pain. Three changes that occur during pregnancy and contribute to somatic dysfunction are: 1) hormonal changes; 2) changes in body fluid circulation; and 3) structural and biomechanical changes related to the developing fetus.17 The back-related changes that typically occur during the third trimester include increased lumbar lordosis with pelvic tilt, increased thoracic kyphosis, and anterior tilt of the pelvic brim.17 OMT is considered to be a complimentary and alternative medical therapy that may be used during pregnancy to help alleviate the pain associated with these above-mentioned somatic changes (Figure 1).

Figure: Hamstring stretch and lumbar spine articulationFigure: Perpendicular myofascial release of the lumbar parabertebral musclesFigure: Stretches and OMT techniquesFigure 1: Stretches and OMT techniques

Although OMT during pregnancy is potentially a great therapeutic adjunct to obstetrical care, there is limited research conducted on OMT during pregnancy. An observational study reviewing medical records from four sites has found that prenatal OMT was associated with lowered risk of preterm delivery and meconium-stained amniotic fluid at delivery.18 Another study was performed to explore the potential effects of OMT on low back pain in pregnancy. In this randomized controlled trial, women between their 28th and 30th weeks of pregnancy were divided into three test groups.19 Women with high-risk pregnancies were excluded from the trial. The three test groups were: 1) usual obstetrical care and OMT (UOBC+OMT); 2) UOBC and sham ultrasound treatment (UOBC+SUT); and 3) UOBC only. Treatment modalities for the group receiving OMT included soft tissue, myofascial release, muscle energy, and range-of-motion mobilization.20 Treatment protocol prohibited the use of high-velocity low-amplitude (HVLA) techniques and compression of the fourth ventricle (CV-4). The increasing ligamentous laxity that occurs late in pregnancy may pose a risk when performing HVLA techniques and a minor study showed potential of the CV-4 technique to increase uterine contractions in postdate women; thus, having potential to induce premature labor.21

The study measured back pain on an 11-point scale (0 for “no pain” to 10 for “worst possible pain”) and back-specific functioning, as measured by the Roland-Morris Disability Questionnaire (RMDQ).19,22 The results of the study found that the mean pain level decreased in the UOBC+OMT group, remained unchanged in the UOBC+SUT group, and increased in the UOBC-only group over the course of the third trimester until delivery. The results of the RMDQ assessment demonstrated an overall increase in the RMDQ score over time, as expected secondary to normal progression of pregnancy. However, the study found that back-specific functioning deteriorated less in the UOBC+OMT group than in the UOBC+SUT and UOBC-only groups.19 The researchers noted some limitation to the study. First, the OMT protocol was limited to the third trimester of pregnancy, whereas in clinical practice OMT can be utilized throughout pregnancy. Second, the OMT was standardized for consistency within the trial but may not adequately reflect the benefits of an individualized approach to therapy.17 Despite these limitations and the need for further research, it seems there is clinical benefit in the use of OMT in pregnancy-related back pain.

Other Management Options
As noted, other options are also available to assist in reducing pregnancy-related back pain. Periods of rest with hip flexion exercises can help temporarily decrease pain by reducing the lumbar lordosis. This is accomplished by having the patient lie in the lateral recumbent position with her hips and knees flexed and a pillow used between the knees or below the abdomen for support.23 Additionally, support belts may be used, flexion exercises will help strengthen the abdominal core muscles, and extension exercises will help strengthen the paraspinal muscles.24-27 Acupuncture and water therapy are also good alternative options.28-33 The ACOG suggests additional interventions to ease back pain during pregnancy (Table 1).34

Table: Interventions to ease back pain during pregnancy

If medical therapy is indicated, options are available but limited. Acetaminophen would be the drug of choice.5 Non-steroidal anti-inflammatory drugs (NSAIDs) are classified by the FDA as pregnancy category C in the first and second trimesters. However, NSAIDs should be avoided in the third trimester because inhibition of prostaglandin synthesis may potentially cause premature closure of the ductus arteriosus.35,36

Conclusion
Various options exist for the management of low back pain during pregnancy, ranging from stretching/exercises to medications to more conservative approaches like OMT. The pilot study by Licciardone et al, “demonstrated clinical benefits without appreciable harms in back-specific functioning when OMT is provided as complementary therapy during the third trimester of pregnancy” and that “OMT lessens or halts the deterioration in back-specific function.”19 The outcomes regarding back pain itself have also suggested there is clinical benefit to the use of complementary OMT.

Somatic alterations during pregnancy, like changes in body habits, fluids, spinal curvature, joint laxity, and hormonal responses, may all contribute to the development of pain. Further exploration of the effects of OMT on patients experiencing low back pain during pregnancy is needed. OMT offers additional therapeutic techniques that have potential to improve patient quality of life.

Last updated on: October 5, 2012
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